Provider Demographics
NPI:1265281463
Name:BURGESS, BRYCE T (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:T
Last Name:BURGESS
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 E JUSTINE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1946
Mailing Address - Country:US
Mailing Address - Phone:317-840-2795
Mailing Address - Fax:
Practice Address - Street 1:370 E VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1214
Practice Address - Country:US
Practice Address - Phone:602-258-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ221746363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care