Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 1575 | WY |
NPI | 1013398247 |
---|---|
Provider Name | Matthew Burks |
First Address | Cheyenne, WY 82009-4867 |
Second Address | Cheyenne, WY 82009-4867 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/06/2015 |
Last Update Date | 12/06/2015 |