Basic Information
| Provider Information | |||||||||
| NPI: | 1841378247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGETT | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1193 HARRISON ST S | ||||||||
| Address2: | |||||||||
| City: | SHAKOPEE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553792039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125687730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596004645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 207037 | MN | N | Nursing Service Providers | Registered Nurse | 163W00000X | 682122 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 075372 | CT | N | Nursing Service Providers | Registered Nurse | 363L00000X | 7371 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 16637 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | AP4292 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LP0808X | AP4293 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 16637 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 75656 | 05 | AZ | MEDICAID |