1982195277 NPI number — ISABEL E BURGESS PA-C

Table of content: ISABEL E BURGESS PA-C (NPI 1982195277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982195277 NPI number — ISABEL E BURGESS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
ISABEL
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BETANCOURT OTANEZ
Provider Other First Name:
ISABEL
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982195277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9007
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTESVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22906-9007
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:
1240 LEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTESVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22908-0817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-924-9333
Provider Business Practice Location Address Fax Number:
434-244-7526
Provider Enumeration Date:
05/23/2018

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: 363A00000X , with the licence number:  PA9111239 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110007894 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 025047600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com