Provider Demographics
NPI:1306861315
Name:MAUGHAN, BURKE D (MSPT)
Entity Type:Individual
Prefix:
First Name:BURKE
Middle Name:D
Last Name:MAUGHAN
Suffix:
Gender:M
Credentials:MSPT
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 66
Mailing Address - Street 2:
Mailing Address - City:HOOPER
Mailing Address - State:UT
Mailing Address - Zip Code:84315-0066
Mailing Address - Country:US
Mailing Address - Phone:801-689-0200
Mailing Address - Fax:801-689-0201
Practice Address - Street 1:5957 FASHION POINT DR STE 102
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5180
Practice Address - Country:US
Practice Address - Phone:801-827-0200
Practice Address - Fax:801-827-0201
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT317074-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105803Medicare PIN
AZP00933Medicare UPIN