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General NPI Number Information
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NPI Number | 1629485909
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Entity Type | Individual
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Provider Name | KRYSTA-GAYE LATOYA BURCHENSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/17/2014
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Last Update Date | 10/20/2014
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Provider Practice Location Address
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Address Line | 1515 SW ARCHER RD
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City | GAINESVILLE
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State | FL
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Zip | 32608-1134
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Country | US
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Telephone | 352-265-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 3403 FOXCROFT RD
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City | MIRAMAR
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State | FL
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Zip | 33025-4186
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Country | US
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Telephone | 954-445-7871
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA 9108009
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License Number State | FL
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