Basic Information
Provider Information | |||||||||
NPI: | 1669625083 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURSCH | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RNSA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2820 GRIFFIN AVE STE 210 | ||||||||
Address2: |   | ||||||||
City: | ENUMCLAW | ||||||||
State: | WA | ||||||||
PostalCode: | 980222373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608257500 | ||||||||
FaxNumber: | 3608253370 | ||||||||
Practice Location | |||||||||
Address1: | 2820 GRIFFIN AVE STE 210 | ||||||||
Address2: |   | ||||||||
City: | ENUMCLAW | ||||||||
State: | WA | ||||||||
PostalCode: | 980222373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608257500 | ||||||||
FaxNumber: | 3608253370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2008 | ||||||||
LastUpdateDate: | 10/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | 00058788 | WA | Y |   | Nursing Service Providers | Registered Nurse | Medical-Surgical |
ID Information
ID | Type | State | Issuer | Description | 0032165 | 01 | WA | LABOR & INDUSTRIES | OTHER |