Provider Demographics
NPI:1750602322
Name:BURKETT, GEORGE EDWARD (MEDICAL MASSAGE)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:EDWARD
Last Name:BURKETT
Suffix:
Gender:M
Credentials:MEDICAL MASSAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21578 IREDELL TER
Mailing Address - Street 2:
Mailing Address - City:BROADLANDS
Mailing Address - State:VA
Mailing Address - Zip Code:20148-5033
Mailing Address - Country:US
Mailing Address - Phone:703-858-9198
Mailing Address - Fax:
Practice Address - Street 1:21578 IREDELL TER
Practice Address - Street 2:
Practice Address - City:BROADLANDS
Practice Address - State:VA
Practice Address - Zip Code:20148-5033
Practice Address - Country:US
Practice Address - Phone:703-858-9198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019006812174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019006812OtherVA BOARD OF NURSING