Provider Demographics
NPI:1184201782
Name:BURDINE, TYRISA (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:TYRISA
Middle Name:
Last Name:BURDINE
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 THORNTON RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-1589
Mailing Address - Country:US
Mailing Address - Phone:865-455-8410
Mailing Address - Fax:
Practice Address - Street 1:351 THORNTON RD STE 118
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1589
Practice Address - Country:US
Practice Address - Phone:865-455-8410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1312751744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty