Provider Demographics
NPI:1699354258
Name:BURGOON, MYA A
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:A
Last Name:BURGOON
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 1:8000 JOHNSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9403
Mailing Address - Country:US
Mailing Address - Phone:704-258-8439
Mailing Address - Fax:
Practice Address - Street 1:8000 JOHNSON CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-9403
Practice Address - Country:US
Practice Address - Phone:704-258-8439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay