MEDICARE: MR. JACOB DAVID BURKART

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2521	WV
2	390200000X	Student in an Organized Health Care Education/Training Program
3	363A00000X	Physician Assistant	PA61559558	WA

General Provider Information

NPI Number	:	1457949448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB DAVID BURKART

Provider Business Mailing Address
First Line	:	5633 N LIDGERWOOD ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208-1224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5633 N. LIDGERWOOD ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99208
Country	:	US
Telephone Number	:	121-091-0893
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	03/13/2026

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