Provider Demographics
NPI:1952187965
Name:BUSH, NATHAN TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:TYLER
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 1:896 N 104 W
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9626
Mailing Address - Country:US
Mailing Address - Phone:219-928-6808
Mailing Address - Fax:
Practice Address - Street 1:601 GATEWAY BLVD N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9658
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-921-5303
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004155A363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty