Healthcare Provider Details

I. General information

NPI: 1881551802
Provider Name (Legal Business Name): ANDI BURGESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36301 LAKE RD
SHAWNEE OK
74801-2321
US

IV. Provider business mailing address

36301 LAKE RD
SHAWNEE OK
74801-2321
US

V. Phone/Fax

Practice location:
  • Phone: 405-765-2624
  • Fax:
Mailing address:
  • Phone: 405-765-2624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3961
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: