Provider Demographics
NPI:1023665619
Name:BURGOS, KATRINA
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6438 WILMINGTON PIKE STE 110
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7021
Mailing Address - Country:US
Mailing Address - Phone:937-848-4121
Mailing Address - Fax:937-848-5965
Practice Address - Street 1:6438 WILMINGTON PIKE STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7021
Practice Address - Country:US
Practice Address - Phone:937-848-4121
Practice Address - Fax:937-848-5965
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006085RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.006085RXOtherOH MEDICAL LICENSE (PHYSICIAN ASSISTANT)