Provider Demographics
NPI:1649379413
Name:BURKE-PRICE, EILEEN
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:BURKE-PRICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680670
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84068-0670
Mailing Address - Country:US
Mailing Address - Phone:435-649-7640
Mailing Address - Fax:435-649-1365
Practice Address - Street 1:1665 BONANZA DRIVE
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-649-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363605-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ06260Medicare UPIN
UT5576611Medicare ID - Type Unspecified