Provider Demographics
NPI:1053757229
Name:BUSH, STEPHEN (MA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 QUEENSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7600
Mailing Address - Country:US
Mailing Address - Phone:518-793-4978
Mailing Address - Fax:
Practice Address - Street 1:68 QUEENSBURY AVE
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7600
Practice Address - Country:US
Practice Address - Phone:518-793-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18515174400000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist