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General NPI Number Information
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NPI Number | 1093280307
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Entity Type | Individual
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Provider Name | SHANNON F BURBANK
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Gender | Female
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Dates
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Enumeration Date | 10/12/2018
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Last Update Date | 10/12/2018
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Provider Practice Location Address
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Address Line | 1127 CALDWELL BLVD
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City | NAMPA
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State | ID
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Zip | 83651-1701
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Country | US
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Telephone | 209-465-4935
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Fax |
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Provider Business Mailing Address
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Address Line | 2697 W LOS FLORES CT
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City | MERIDIAN
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State | ID
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Zip | 83646-5468
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Country | US
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Telephone | 120-888-4382
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5839
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License Number State | ID
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