Provider Demographics
NPI:1619414984
Name:BUSCH, RYAN THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:THOMAS
Last Name:BUSCH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 BAKER ST FL 3
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-2157
Mailing Address - Country:US
Mailing Address - Phone:231-737-1335
Mailing Address - Fax:231-737-0534
Practice Address - Street 1:2700 BAKER ST FL 3
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-2157
Practice Address - Country:US
Practice Address - Phone:231-737-1335
Practice Address - Fax:231-737-0534
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1619414984Medicaid