Provider Demographics
NPI:1497375869
Name:BUSH, DEREK JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:BUSH
Suffix:
Gender:M
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 1:75 BEEKMAN ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1427
Mailing Address - Country:US
Mailing Address - Phone:185-627-3715
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1427
Practice Address - Country:US
Practice Address - Phone:518-562-7371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-25
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY026302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant