Provider Demographics
NPI:1902358849
Name:RUSH, KALEB PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KALEB
Middle Name:PAUL
Last Name:RUSH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50354 STATE ROUTE 145
Mailing Address - Street 2:
Mailing Address - City:WOODSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43793-9217
Mailing Address - Country:US
Mailing Address - Phone:740-472-4614
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43713-1005
Practice Address - Country:US
Practice Address - Phone:740-425-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004880RX363A00000X
WV727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant