MEDICARE: MS. DARIA BUSH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	48087375	TX

General Provider Information

NPI Number	:	1306632419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DARIA BUSH

Provider Business Mailing Address
First Line	:	12430 KINGS PATH LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77044-6299
Country	:	US
Telephone Number	:	713-344-6783
Fax Number	:

Provider Business Practice Location Address
First Line	:	12430 KINGS PATH LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77044-6299
Country	:	US
Telephone Number	:	713-344-6783
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2025
Last Update Date	:	04/16/2025

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