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General NPI Number Information
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NPI Number | 1285998195
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Entity Type | Individual
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Provider Name | MALIA ALYS BURGESS PTA
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Gender | Female
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Dates
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Enumeration Date | 06/26/2012
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 12400 HIGH BLUFF DR
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City | SAN DIEGO
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State | CA
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Zip | 92130-3077
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Country | US
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Telephone | 866-871-8519
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Fax |
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Provider Business Mailing Address
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Address Line | 2125 CLEARVIEW AVE
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City | FORT COLLINS
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State | CO
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Zip | 80521-4209
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Country | US
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Telephone | 360-201-8573
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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 | P160043572
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA-12149
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License Number State | CO
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