Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225X00000X | Occupational Therapist | OT461 | ID |
Y | 225XH1200X | Occupational Therapist - Hand | OT-461 | ID |
NPI | 1053480236 |
---|---|
Provider Name | Eric S Burback |
First Address | Boise, ID 83706-1341 |
Second Address | Boise, ID 83706-1341 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2006 |
Last Update Date | 05/06/2020 |