Provider Demographics
NPI:1952518060
Name:BURKE, LOUIS A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:A
Last Name:BURKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 EAST OVERLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-884-8300
Mailing Address - Fax:
Practice Address - Street 1:3875 EAST OVERLAND ROAD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-884-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805396900Medicaid
ID5943480001Medicare NSC
ID1665091Medicare PIN
ID11371462Medicare PIN