Provider Demographics
NPI:1710058482
Name:BURKE, WILLIAM JON (PT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JON
Last Name:BURKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11177 LAMBS LN
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-9779
Mailing Address - Country:US
Mailing Address - Phone:740-763-0408
Mailing Address - Fax:740-763-0485
Practice Address - Street 1:812 COSHOCTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1947
Practice Address - Country:US
Practice Address - Phone:740-392-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2595053Medicaid
OH2595053Medicaid