1962417311 NPI number — JACQUELINE BURBANK PT

Table of content: LISA NATASHA MARTIN APN (NPI 1801430285)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962417311 NPI number — JACQUELINE BURBANK PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURBANK
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962417311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4428 E CUB RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83263-5575
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 N 27TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILLINGS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59101-0760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-238-5589
Provider Business Practice Location Address Fax Number:
406-238-5266
Provider Enumeration Date:
07/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PTP-PT-LIC-2198 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 7959 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT-2009 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 329940-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)