Basic Information
| Provider Information | |||||||||
| NPI: | 1629215546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSHNELL | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3101 EMRICK BLVD | ||||||||
| Address2: | 112 | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180208037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109975750 | ||||||||
| FaxNumber: | 6109975762 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 EMRICK BLVD | ||||||||
| Address2: | 112 | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180208037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109975750 | ||||||||
| FaxNumber: | 6109975762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2009 | ||||||||
| LastUpdateDate: | 01/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 27338734 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 27338734 | 01 | PA | PENNSYLVANIA LICENSE | OTHER |