Provider Demographics
NPI:1346670957
Name:BUSH, GAVIN JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:JOHN
Last Name:BUSH
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:PO BOX 31001-4110
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-4110
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-5606
Practice Address - Street 1:500 W BROADWAY ST STE 320
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-5606
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2025-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA164984363A00000X
MTMED-PAC-LIC-144296363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant