Healthcare Provider Details

I. General information

NPI: 1811545684
Provider Name (Legal Business Name): SHELDON SKYLER BURGESS ATC, LAT, CSMS-1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 W EMERALD ST
BOISE ID
83704-8613
US

IV. Provider business mailing address

6325 S ROCKROSE WAY
BOISE ID
83716-7133
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3500
  • Fax:
Mailing address:
  • Phone: 208-761-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-696
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: