Provider Demographics
NPI:1013775238
Name:BUSCH, RILEY B (PA-C)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:B
Last Name:BUSCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1200 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-4979
Mailing Address - Country:US
Mailing Address - Phone:573-876-7105
Mailing Address - Fax:
Practice Address - Street 1:13861 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-4503
Practice Address - Country:US
Practice Address - Phone:636-220-9333
Practice Address - Fax:636-220-9334
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024006272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty