Basic Information
| Provider Information | |||||||||
| NPI: | 1396981049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSBOOM | ||||||||
| FirstName: | KARLA | ||||||||
| MiddleName: | ELAINE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CROSE | ||||||||
| OtherFirstName: | KARLA | ||||||||
| OtherMiddleName: | ELAINE | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13616 CALIFORNIA ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681545336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024965517 | ||||||||
| FaxNumber: | 4024960517 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 W 6TH ST | ||||||||
| Address2: | STE 124 | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660442215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439125 | ||||||||
| FaxNumber: | 7858436973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2008 | ||||||||
| LastUpdateDate: | 06/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200597400A | 05 | KS | MEDICAID |