Healthcare Provider Details

I. General information

NPI: 1538216650
Provider Name (Legal Business Name): BETH ANN BUSHIE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 COMMERCE DR
NORTH MANKATO MN
56003-1913
US

IV. Provider business mailing address

114 MERLIN CIR
MANKATO MN
56001-5732
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-8017
  • Fax: 507-625-2325
Mailing address:
  • Phone: 507-345-4360
  • Fax: 507-625-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1573
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: