Provider Demographics
NPI:1902141237
Name:BRUSH, RANDY JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:JOSEPH
Last Name:BRUSH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-234-4016
Mailing Address - Fax:574-251-2095
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 210
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-234-4016
Practice Address - Fax:574-251-2095
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN99054700A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical