Provider Demographics
NPI:1689214819
Name:BUSH, RAHEEN (PA)
Entity Type:Individual
Prefix:
First Name:RAHEEN
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2774 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-1808
Mailing Address - Country:US
Mailing Address - Phone:239-332-3480
Mailing Address - Fax:
Practice Address - Street 1:10840 N US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484-3558
Practice Address - Country:US
Practice Address - Phone:239-332-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant