Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT-1869 | WY |
NPI | 1043878408 |
---|---|
Provider Name | Cossette Burnham |
First Address | Jackson, WY 83002-8467 |
Second Address | Jackson, WY 83001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2019 |
Last Update Date | 31/05/2019 |