MEDICARE: MR. MONTE CARL BURNAM P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA10764	CA

General Provider Information

NPI Number	:	1639129729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MONTE CARL BURNAM P.A.-C

Provider Business Mailing Address
First Line	:	1145 AMELIA DR.
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807
Country	:	US
Telephone Number	:	818-528-2500
Fax Number	:	818-528-2505

Provider Business Practice Location Address
First Line	:	16260 VENTURA BLVD
Second Line	:	140
City	:	ENCINO
State	:	CA
Zip	:	91436-2203
Country	:	US
Telephone Number	:	818-528-2500
Fax Number	:	818-528-2505

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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