=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538523964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER BRYAN BUSH NP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2016
-----------------------------------------------------
Last Update Date | 12/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 PHOENIX BLVD STE 600
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-5596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-257-2547
-----------------------------------------------------
Fax | 404-795-5832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3237 SATELLITE BLVD STE 425
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-9009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-257-2547
-----------------------------------------------------
Fax | 404-795-5832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN204646
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------