Provider Demographics
NPI:1053657288
Name:BURGENER, PAUL PHILLIP (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:PHILLIP
Last Name:BURGENER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 NW CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 NW CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2492
Practice Address - Country:US
Practice Address - Phone:772-871-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-16
Last Update Date:2012-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20482225100000X
GAPT007594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist