Provider Demographics
NPI:1477277523
Name:BURGESS, COURTNEY JEWEL (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JEWEL
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 PECAN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75072-8323
Mailing Address - Country:US
Mailing Address - Phone:469-525-5710
Mailing Address - Fax:
Practice Address - Street 1:1500 E FAIRVIEW AVE # 461
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2114
Practice Address - Country:US
Practice Address - Phone:469-525-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT9476204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1477277523OtherNPI