Provider Demographics
NPI:1760497697
Name:BUSH, CASSANDRA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:RENEE
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:RENEE
Other - Last Name:STIPATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3525 RICHARD ARRINGTON JR BLVD N
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35234-2307
Mailing Address - Country:US
Mailing Address - Phone:205-705-3180
Mailing Address - Fax:205-705-3189
Practice Address - Street 1:3525 RICHARD ARRINGTON JR BLVD N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35234-2307
Practice Address - Country:US
Practice Address - Phone:205-705-3180
Practice Address - Fax:205-705-3189
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA805363A00000X, 363A00000X
CAPA17735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
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CAPA17735Medicaid
CA1225222029OtherMEDICARE PART B DME
CAPA177350OtherPHYS ASSIST LICENSE
CAE62601Medicare UPIN
CA1649277088OtherSTANLEY SCHINKE MD
CAG05779Medicare UPIN
CAZZZ28984ZMedicare ID - Type UnspecifiedMEDICARE FOR PRACTICE
CA05D1062719OtherCLIA NUMBER
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CA1558368605OtherEVELYN MENDOZA MD
CA1962696344OtherMEDICARE PART B DME
CA5945420002OtherMEDICARE PART D DME
CAE33311Medicare UPIN
CA5945420001OtherMEDICARE PART D DME