Provider Demographics
NPI:1669708657
Name:BUSH, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1479
Mailing Address - Country:US
Mailing Address - Phone:928-773-2505
Mailing Address - Fax:
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1479
Practice Address - Country:US
Practice Address - Phone:928-773-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ082696367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered