Provider Demographics
NPI:1114037520
Name:BUSE, JUDY LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:LYNN
Last Name:BUSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 HIAWATHA WAY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3539
Mailing Address - Country:US
Mailing Address - Phone:321-728-2108
Mailing Address - Fax:
Practice Address - Street 1:1995 W NASA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-2300
Practice Address - Country:US
Practice Address - Phone:321-722-4443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0624Medicare ID - Type Unspecified