Provider Demographics
NPI:1114013588
Name:BURGE, KATHY (FNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BURGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 CLARK RD STE 206
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3229
Mailing Address - Country:US
Mailing Address - Phone:941-921-2617
Mailing Address - Fax:941-921-3399
Practice Address - Street 1:5310 CLARK RD STE 206
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-3229
Practice Address - Country:US
Practice Address - Phone:941-921-2617
Practice Address - Fax:941-921-3399
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9473743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007782462Medicaid
WV0001209000Medicaid
WV0001209000Medicaid