Provider Demographics
NPI:1558074955
Name:BURKE, NATHAN THOMPSON (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMPSON
Last Name:BURKE
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:287 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6045
Practice Address - Country:US
Practice Address - Phone:208-322-1680
Practice Address - Fax:208-385-7708
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID70954363LA2100X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care