Provider Demographics
NPI:1477565943
Name:BURKERT, PENNY (PA-C)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:BURKERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 S RURAL RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3793
Mailing Address - Country:US
Mailing Address - Phone:480-831-0600
Mailing Address - Fax:480-820-3065
Practice Address - Street 1:6655 S RURAL RD
Practice Address - Street 2:SUITE 3
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3793
Practice Address - Country:US
Practice Address - Phone:480-831-0600
Practice Address - Fax:480-820-3065
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1492363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS57760Medicare UPIN
AZ109061Medicare ID - Type Unspecified