Provider Demographics
NPI:1114213832
Name:BURKS, NATHAN T (DPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:T
Last Name:BURKS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1975
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-1975
Mailing Address - Country:US
Mailing Address - Phone:386-597-7962
Mailing Address - Fax:866-929-6036
Practice Address - Street 1:70 TOWN CT
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-2540
Practice Address - Country:US
Practice Address - Phone:386-597-7962
Practice Address - Fax:866-929-6036
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 29626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHX687YMedicare PIN
TN446631Medicare PIN
FLHX687ZMedicare PIN