Provider Demographics
NPI:1457481749
Name:BURCIAGA, STELLA JEANNE (PT)
Entity Type:Individual
Prefix:MISS
First Name:STELLA
Middle Name:JEANNE
Last Name:BURCIAGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 ROADRUNNER
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701
Mailing Address - Country:US
Mailing Address - Phone:505-718-8309
Mailing Address - Fax:
Practice Address - Street 1:601 E LINCOLN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4502
Practice Address - Country:US
Practice Address - Phone:505-425-2998
Practice Address - Fax:505-425-2897
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM36072842Medicaid
NMNMB2181Medicare UPIN