Provider Demographics
NPI:1245254473
Name:BURK, PHILLIP S (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:S
Last Name:BURK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 W STANLEY ST
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:WA
Practice Address - Zip Code:98252-8631
Practice Address - Country:US
Practice Address - Phone:360-691-2419
Practice Address - Fax:360-691-0489
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8913930Medicaid
AB06874Medicare ID - Type Unspecified
WA8913930Medicaid