Healthcare Provider Details

I. General information

NPI: 1013538727
Provider Name (Legal Business Name): NYSSA BURDICK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 01/09/2024
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNMRTU IWAKUNI, BLDG 110, MCAS IWAKUNI, 1 MISUMI MACHI
IWAKUNI YAMAGUCHI
7400025
JP

IV. Provider business mailing address

PSC 561 BOX 1877
FPO AP
96310-0019
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: