Provider Demographics
NPI:1649752502
Name:BUSH, KARON (APRN)
Entity Type:Individual
Prefix:
First Name:KARON
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12013 RANDALL WOODS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4544
Mailing Address - Country:US
Mailing Address - Phone:706-566-7726
Mailing Address - Fax:
Practice Address - Street 1:12013 RANDALL WOODS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-4544
Practice Address - Country:US
Practice Address - Phone:706-566-7726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR060034363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00837801AMedicaid