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NPI Code Detail

MEDICARE: KRISTIAN DEREK BURGESS DO

MEDICARE: KRISTIAN DEREK BURGESS DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianOT018627PA
2207Q00000XFamily Medicine PhysicianDO2931NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3DO2931OTHERNVSTATE LICENSE

General Provider Information

NPI Number : 1457844292
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTIAN DEREK BURGESS DO
Provider Business Mailing Address
First Line : 6355 S BUFFALO DR FL 3
Second Line :
City : LAS VEGAS
State : NV
Zip : 89113-2133
Country : US
Telephone Number : 702-216-3346
Fax Number : 702-671-6883
Provider Business Practice Location Address
First Line : 786 W PIONEER BLVD STE A
Second Line :
City : MESQUITE
State : NV
Zip : 89027-8862
Country : US
Telephone Number : 702-345-5000
Fax Number : 702-345-2000
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/06/2018
Last Update Date : 10/17/2022

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Directions to “ KRISTIAN DEREK BURGESS DO” Practice Location

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