Provider Demographics
NPI:1497346225
Name:BURGARD, AMY MARIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:BURGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MADISON ST NE # 222
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7862
Mailing Address - Country:US
Mailing Address - Phone:503-393-4273
Mailing Address - Fax:
Practice Address - Street 1:2555 SILVERTON RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0837
Practice Address - Country:US
Practice Address - Phone:503-393-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000004327175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000004327OtherTRADITIONAL HEALTH WORKER REGISTRY