Provider Demographics
NPI:1134639438
Name:BUSH, PEGGY KORTZ (APN)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:KORTZ
Last Name:BUSH
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10005 SW TYLER TER
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-5903
Mailing Address - Country:US
Mailing Address - Phone:772-872-2789
Mailing Address - Fax:
Practice Address - Street 1:2601 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4622
Practice Address - Country:US
Practice Address - Phone:772-219-2777
Practice Address - Fax:772-219-0017
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNS9363204364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty