Provider Demographics
NPI:1023743960
Name:BUSHMAN, IVAN SCOTT (RN)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:SCOTT
Last Name:BUSHMAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19044 N LOUSANDRA DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5774
Mailing Address - Country:US
Mailing Address - Phone:602-369-4670
Mailing Address - Fax:
Practice Address - Street 1:775 E WILLETTA ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2723
Practice Address - Country:US
Practice Address - Phone:480-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN183610163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse