1790745446 NPI number — RICHARD WAYNE BURRIS PA-C

Table of content: RICHARD WAYNE BURRIS PA-C (NPI 1790745446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790745446 NPI number — RICHARD WAYNE BURRIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRIS
Provider First Name:
RICHARD
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790745446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
257 W SAINT GEORGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANTSBURG
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54840-7827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-463-5353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 W SAINT GEORGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTSBURG
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-463-5353
Provider Business Practice Location Address Fax Number:
715-463-2753
Provider Enumeration Date:
03/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  4333-23 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 9113 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 449390700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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