Healthcare Provider Details

I. General information

NPI: 1881567980
Provider Name (Legal Business Name): MR. CARL ALEXIS BUSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W MAIN STREET
EVERSON WA
98247-8250
US

IV. Provider business mailing address

8448 118 STREET NW.
EDMONTON AB
T6G IT3
CA

V. Phone/Fax

Practice location:
  • Phone: 360-788-4228
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: