=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760497697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSANDRA RENEE BUSH PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2006
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3525 RICHARD ARRINGTON JR BLVD N
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35234-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-705-3180
-----------------------------------------------------
Fax | 205-705-3189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 RICHARD ARRINGTON JR BLVD N
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35234-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-705-3180
-----------------------------------------------------
Fax | 205-705-3189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA805
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------