Provider Demographics
NPI:1639466873
Name:BUSEY, BLAKE RON (DO)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:RON
Last Name:BUSEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 NE KRESKY AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2412
Mailing Address - Country:US
Mailing Address - Phone:360-330-9543
Mailing Address - Fax:360-330-9560
Practice Address - Street 1:1800 COOKS HILL RD STE F
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9162
Practice Address - Country:US
Practice Address - Phone:360-669-0335
Practice Address - Fax:360-736-2967
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61205149207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2221982Medicaid