Healthcare Provider Details

I. General information

NPI: 1104570142
Provider Name (Legal Business Name): KAITLIN BUSH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 SLATE AVE
OWINGSVILLE KY
40360-2206
US

IV. Provider business mailing address

PO BOX 1120
OWINGSVILLE KY
40360-1120
US

V. Phone/Fax

Practice location:
  • Phone: 606-674-6386
  • Fax: 606-674-3096
Mailing address:
  • Phone: 606-674-6386
  • Fax: 606-674-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1192698
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: