Healthcare Provider Details

I. General information

NPI: 1346414752
Provider Name (Legal Business Name): NICHOLAS I BUSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE NEFF RD
BEND OR
97701-6015
US

IV. Provider business mailing address

PO BOX 6095
BEND OR
97708-6095
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-4333
  • Fax: 541-388-3446
Mailing address:
  • Phone: 541-706-5922
  • Fax: 541-706-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0420012193
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number65190-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number65190-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0420012193
License Number StateVT
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMD191669
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: