Basic Information
| Provider Information | |||||||||
| NPI: | 1780766055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHUE | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | FRANCES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3857 MARTIN WAY E | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607047170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4422 6TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985031020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607047170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | AP30001162 | WA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 9607375 | 05 | WA | MEDICAID |