Provider Demographics
NPI:1730164831
Name:BUSHONG, TOBIN JAY (PA)
Entity type:Individual
Prefix:MR
First Name:TOBIN
Middle Name:JAY
Last Name:BUSHONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4509
Mailing Address - Country:US
Mailing Address - Phone:713-436-3488
Mailing Address - Fax:713-436-3860
Practice Address - Street 1:12835 GULF FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034-4807
Practice Address - Country:US
Practice Address - Phone:713-436-3488
Practice Address - Fax:713-436-3860
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03483363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328967001Medicaid
TX8364NDOtherBLUE CROSS BLUE SHIELD
TX8364NDOtherBLUE CROSS BLUE SHIELD
TX312025YMVQMedicare PIN
TX503229ZSWDMedicare PIN