Basic Information
| Provider Information | |||||||||
| NPI: | 1013495407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSAM | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 935 SHOTWELL RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195500821 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 935 SHOTWELL RD STE 108 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193295000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.000000 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.