Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC5007 | AZ |
NPI | 1407098064 |
---|---|
Provider Name | Dr. Gary Lynn Burk |
First Address | Mesa, AZ 85213-1685 |
Second Address | Mesa, AZ 85213-1685 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2009 |
Last Update Date | 28/03/2009 |