Provider Demographics
NPI:1174565022
Name:BUSH, LAURA P (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:P
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 LANIER AVE WEST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-460-8988
Mailing Address - Fax:770-460-0727
Practice Address - Street 1:450 LANIER AVE WEST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-460-8988
Practice Address - Fax:770-460-0727
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36378363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCGLRMedicare ID - Type Unspecified
GAS35610Medicare UPIN