Basic Information
| Provider Information | |||||||||
| NPI: | 1518309350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURDICK | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | FPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 S YALE ST | ||||||||
| Address2: | 252 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287741811 | ||||||||
| FaxNumber: | 9287742006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S YALE ST | ||||||||
| Address2: | 252 | ||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287741811 | ||||||||
| FaxNumber: | 9287742006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2013 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN125139 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.