Provider Demographics
NPI:1982195277
Name:BURGESS, ISABEL E (PA-C)
Entity Type:Individual
Prefix:
First Name:ISABEL
Middle Name:E
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ISABEL
Other - Middle Name:E
Other - Last Name:BETANCOURT OTANEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0817
Practice Address - Country:US
Practice Address - Phone:434-924-9333
Practice Address - Fax:434-244-7526
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111239363A00000X
VA0110007894363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025047600Medicaid