Kenneth Wayne Bush, PA
Individual provider Active NPI Physician Assistant · Clemmons, NC
NPI 1528020682 · NPPES record last updated Jun 23, 2025
Key facts
- NPI
- 1528020682
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 103038 (NC)
- Practice address
- 2311 Lewisville Clemmons Rd
Clemmons, NC 27012-8905 - Phone
- (336) 716-2255
- NPI assigned
- Apr 4, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 19
Hospital & facility affiliations 5
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 2004
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Carolina Medicorp Enterprises LLC
Wake Forest University Health Sciences
Practice addresses (Care Compare)
105 Hanes Square Cir
Winston Salem, NC 27103-5514
Phone (336) 441-5569
3163 Gammon LN
Clemmons, NC 27012-9052
Phone (336) 310-5571
601 N Elm St
High Point, NC 27262-4331
Phone (336) 716-2734
Medical Ctr Blvd
Winston Salem, NC 27157-0001
Phone (336) 716-2734
Hospital & facility affiliations
- North Carolina Baptist Hospital
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NC
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20100513000654 | NC | Practitioner - Physician Assistant | 5193853067 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 103038 | NC | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Wake Forest University Health Sciences | Current |
Accepting new patients | |
| Carolina Medicorp Enterprises, LLC | Current |
Accepting new patients | |
| Carolina Medicorp Enterprises Inc | Past | Accepting new patients |
Locations
9550 Rocky River Rd
Ste 150
Charlotte, NC 28215
Phone (704) 457-1510
2311 Lewisville Clemmons Rd
Clemmons, NC 27012
Phone (336) 713-0400
Medical Ctr Blvd
Winston Salem, NC 27157
Phone (336) 713-2697
600 Highland Oaks Dr
Winston Salem, NC 27103
Phone (366) 774-0040
105 Hanes Square Cir
Winston Salem, NC 27103
Phone (336) 441-5569
Interoperability endpoints
- kbush2755616@carolinashealthcaresystem.direct-ci.com
- kbush5727@direct.novanthealth.org
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 103038 | NC | Yes |
Addresses
Primary practice location
2311 Lewisville Clemmons Rd
Clemmons, NC 27012-8905
Mailing address
PO Box 602658
Charlotte, NC 28260-2658
Phone (336) 716-2255
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 8101650 | Medicaid | NC |
Other providers in Clemmons, NC
- Michelle Germaine Brown
- Lindsay Grace Brumfield
- Brittany Bumgarner
- Mary Katherine Burbach
- Judi A. Burkhart
- Bypeterson Properties, LLC
- Xiuwei Cai
- Larry Jason Calloway
- Calming Corner Counseling
- Camel City Chiropractic and Injury
All providers in Clemmons, NC · Physician Assistant in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 23, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.