MEDICARE: MS. MARIA BUSHMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1013122563	OTHER	ID	LDS FAMILY SERVICES

General Provider Information

NPI Number	:	1891117750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIA BUSHMAN

Provider Business Mailing Address
First Line	:	1418 FILLMORE ST
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3380
Country	:	US
Telephone Number	:	208-735-2237
Fax Number	:

Provider Business Practice Location Address
First Line	:	1418 FILLMORE ST
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-3380
Country	:	US
Telephone Number	:	208-735-2237
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2014
Last Update Date	:	01/13/2014

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