Provider Demographics
NPI:1629215546
Name:BUSHNELL, BRANDON (ATC)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:BUSHNELL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 EMRICK BLVD
Mailing Address - Street 2:112
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-8037
Mailing Address - Country:US
Mailing Address - Phone:610-997-5750
Mailing Address - Fax:610-997-5762
Practice Address - Street 1:3101 EMRICK BLVD
Practice Address - Street 2:112
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-8037
Practice Address - Country:US
Practice Address - Phone:610-997-5750
Practice Address - Fax:610-997-5762
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA273387342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA27338734OtherPENNSYLVANIA LICENSE