Provider Demographics
NPI:1245982750
Name:BUSH, KOLTEN (APRN)
Entity type:Individual
Prefix:
First Name:KOLTEN
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 DOGWOOD FLOWER LN APT 103
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6886
Mailing Address - Country:US
Mailing Address - Phone:813-758-9455
Mailing Address - Fax:
Practice Address - Street 1:2300 LOVELAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-5716
Practice Address - Country:US
Practice Address - Phone:941-629-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017693363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner