Provider Demographics
NPI:1811545684
Name:BURGESS, SHELDON SKYLER (ATC, LAT, CSMS-1)
Entity Type:Individual
Prefix:
First Name:SHELDON
Middle Name:SKYLER
Last Name:BURGESS
Suffix:
Gender:M
Credentials:ATC, LAT, CSMS-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6325 S ROCKROSE WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7133
Mailing Address - Country:US
Mailing Address - Phone:208-761-5396
Mailing Address - Fax:
Practice Address - Street 1:6165 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-302-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-6962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer