Provider Demographics
NPI:1376896910
Name:BURKE, DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11167 PROVINCE RD
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:MO
Mailing Address - Zip Code:63648-9513
Mailing Address - Country:US
Mailing Address - Phone:573-749-3808
Mailing Address - Fax:
Practice Address - Street 1:1 GEORGIAN GARDENS DR
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1436
Practice Address - Country:US
Practice Address - Phone:573-436-0691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116295225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant