Provider Demographics
NPI:1376254060
Name:BUSH, ALEXIS M (PA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 SHATTUCK RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3153
Mailing Address - Country:US
Mailing Address - Phone:989-791-5353
Mailing Address - Fax:989-792-3033
Practice Address - Street 1:3570 SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3153
Practice Address - Country:US
Practice Address - Phone:989-791-5353
Practice Address - Fax:989-792-3033
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5601012108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program