Provider Demographics
NPI:1891117750
Name:BUSHMAN, MARIA
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3380
Mailing Address - Country:US
Mailing Address - Phone:208-735-2237
Mailing Address - Fax:
Practice Address - Street 1:1418 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3380
Practice Address - Country:US
Practice Address - Phone:208-735-2237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1013122563OtherLDS FAMILY SERVICES