Provider Demographics
NPI:1578551867
Name:BURROUGHS, JONATHAN NICK (MSPT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:NICK
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 S MAIN ST
Mailing Address - Street 2:SUITE 801
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6637
Mailing Address - Country:US
Mailing Address - Phone:540-951-2703
Mailing Address - Fax:540-953-0873
Practice Address - Street 1:1995 S MAIN ST
Practice Address - Street 2:SUITE 801
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6637
Practice Address - Country:US
Practice Address - Phone:540-951-2703
Practice Address - Fax:540-953-0873
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202962225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA436991OtherANTHEM-BLACKSBURG OFFICE
VA436992OtherANTHEM-PEARISBURG OFFICE
VA0575302OtherAETNA
VA259904OtherMAMSI
VAP63305Medicare UPIN