Healthcare Provider Details

I. General information

NPI: 1982818860
Provider Name (Legal Business Name): KRISTEN MARRON BUSHNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PMG AT 8300 CONSTITUTION - GENERAL SURGERY 8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5330
  • Fax: 505-291-2949
Mailing address:
  • Phone: 505-262-7960
  • Fax: 505-232-1368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2004-0045
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: