Provider Demographics
NPI:1578979936
Name:BUSH, KRISTEN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 RANDOLPH RD
Mailing Address - Street 2:STE 900
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1122
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:1900 RANDOLPH RD
Practice Address - Street 2:STE 900
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1122
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00339000363A00000X
NC0010-05741363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant