Healthcare Provider Details

I. General information

NPI: 1477264489
Provider Name (Legal Business Name): MADISON BURCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

315 N SAN SABA
SAN ANTONIO TX
78207-3154
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-1900
  • Fax: 602-933-1918
Mailing address:
  • Phone: 210-704-4275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19544
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: