Provider Demographics
NPI:1477607471
Name:BURNSIDE, SUSAN KAY (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2241 FOOTHILL BLVD
Mailing Address - Street 2:SUITE 602
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5698
Mailing Address - Country:US
Mailing Address - Phone:307-382-7888
Mailing Address - Fax:307-382-7444
Practice Address - Street 1:2241 FOOTHILL BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5698
Practice Address - Country:US
Practice Address - Phone:307-382-7888
Practice Address - Fax:307-382-7444
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW21086Medicare PIN