Provider Demographics
NPI:1881684819
Name:BUSSNAMAS, NICHOLE L (PAC)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:L
Last Name:BUSSNAMAS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 SE DELAWARE AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-4594
Mailing Address - Country:US
Mailing Address - Phone:515-964-5555
Mailing Address - Fax:515-964-5505
Practice Address - Street 1:1605 SE DELAWARE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4594
Practice Address - Country:US
Practice Address - Phone:515-964-5555
Practice Address - Fax:515-964-5505
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS86745Medicare UPIN