Provider Demographics
NPI:1982621967
Name:BURBANK, NICOLE SHIREE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:SHIREE
Last Name:BURBANK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6300
Practice Address - Fax:208-625-6301
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003009442085R0202X
IDM-96572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00339968OtherRR MEDICARE - RANI
WA8462665Medicaid
ID807559700Medicaid
IDB5645OtherBC ID - PF
IDB5621OtherBC ID - CDA
IDP00425233OtherRR MEDICARE - NIIC
ID76735OtherBC ID - RANI
IDB5645OtherBC ID - PF
ID76735OtherBC ID - RANI
H98984Medicare UPIN