Provider Demographics
NPI:1710045422
Name:BURKE, MARY ANN (RPT)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:BURKE
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 CRESTON RD. #115
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-3033
Mailing Address - Country:US
Mailing Address - Phone:805-227-4156
Mailing Address - Fax:805-227-4899
Practice Address - Street 1:1191 CRESTON RD. #115
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3033
Practice Address - Country:US
Practice Address - Phone:805-227-4156
Practice Address - Fax:805-227-4899
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT16770208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT16770OtherBLUE CROSS
CAPT16770OtherTRICARE
CAGPT001411Medicaid
CAOPT16770OtherBLUE SHIELD
CAPT16770OtherBLUE CROSS