Provider Demographics
NPI:1982818860
Name:BUSHNELL, KRISTEN MARRON (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARRON
Last Name:BUSHNELL
Suffix:
Gender:F
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 1:5400 GIBSON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4729
Mailing Address - Country:US
Mailing Address - Phone:505-262-7960
Mailing Address - Fax:505-232-1368
Practice Address - Street 1:PMG AT 8300 CONSTITUTION - GENERAL SURGERY
Practice Address - Street 2:8300 CONSTITUTION AVE NE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-291-5330
Practice Address - Fax:505-291-2949
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0045363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q40590Medicare UPIN
343512200Medicare PIN
NM57559325Medicaid