Provider Demographics
NPI:1154319820
Name:BUSHROW, KIMBERLY M (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:BUSHROW
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-473-3561
Mailing Address - Fax:
Practice Address - Street 1:1100 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:OH
Practice Address - Zip Code:43469-9723
Practice Address - Country:US
Practice Address - Phone:419-724-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084436Medicaid
OHH092010Medicare PIN