Provider Demographics
NPI:1922232099
Name:BUSSEY, POCCO S (IDMT)
Entity Type:Individual
Prefix:
First Name:POCCO
Middle Name:S
Last Name:BUSSEY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MEDICAL GROUP, FLIGHT MEDICINE CLINIC
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD
Mailing Address - State:WA
Mailing Address - Zip Code:99011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:92 MEDICAL GROUP, FLIGHT MEDICINE CLINIC
Practice Address - Street 2:
Practice Address - City:FAIRCHILD
Practice Address - State:WA
Practice Address - Zip Code:99011
Practice Address - Country:US
Practice Address - Phone:509-247-5755
Practice Address - Fax:509-247-8833
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians