Provider Demographics
NPI:1710906490
Name:BURRESCIA, RICKY T (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:T
Last Name:BURRESCIA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 21ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1135
Mailing Address - Country:US
Mailing Address - Phone:806-793-1406
Mailing Address - Fax:806-796-1167
Practice Address - Street 1:4002 21ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1135
Practice Address - Country:US
Practice Address - Phone:806-793-1406
Practice Address - Fax:806-796-1167
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1008402OtherNCCPA CERTIFICATION
TXPA00664OtherSTATE LICENSE
TX1008402OtherNCCPA CERTIFICATION
TX8A8083Medicare ID - Type UnspecifiedINDIV MCR PROV NO