Provider Demographics
NPI:1194808527
Name:BURICA, INGRID A (PT)
Entity type:Individual
Prefix:MS
First Name:INGRID
Middle Name:A
Last Name:BURICA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 E PARK ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3827
Practice Address - Country:US
Practice Address - Phone:208-634-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT844225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTD518OtherBLUE CROSS
ID000010158289OtherREGENCE BLUE SHIELD
ID000010158289OtherREGENCE BLUE SHIELD
1653375Medicare ID - Type Unspecified