Provider Demographics
NPI:1629408240
Name:BUSBY, KATE FAGAN (LAC)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:FAGAN
Last Name:BUSBY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2427 SE 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1611
Mailing Address - Country:US
Mailing Address - Phone:415-314-1022
Mailing Address - Fax:
Practice Address - Street 1:3115 NE SANDY BOULEVARD
Practice Address - Street 2:SUITE 231
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-701-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR164986171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist