Provider Demographics
NPI:1912139544
Name:BURGETT, RICHARD LAWRENCE SR (CSA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LAWRENCE
Last Name:BURGETT
Suffix:SR
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4327 STONE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7958
Mailing Address - Country:US
Mailing Address - Phone:231-929-7540
Mailing Address - Fax:
Practice Address - Street 1:4327 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7958
Practice Address - Country:US
Practice Address - Phone:231-929-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-15
Last Update Date:2009-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical