Provider Demographics
NPI:1881567980
Name:BUSCH, CARL ALEXIS
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:ALEXIS
Last Name:BUSCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8448 118 STREET NW.
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:AB
Mailing Address - Zip Code:T6G IT3
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-8250
Practice Address - Country:US
Practice Address - Phone:360-788-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program