Provider Demographics
NPI:1578519153
Name:BUSHEY, KEVIN C (APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:BUSHEY
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8319
Mailing Address - Fax:218-786-2891
Practice Address - Street 1:1420 LONDON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2433
Practice Address - Country:US
Practice Address - Phone:218-728-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN412367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN557453600Medicaid
MN557453600Medicaid