Healthcare Provider Details

I. General information

NPI: 1912012998
Provider Name (Legal Business Name): GERALD QUENTIN BURNETT JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72724 29 PALMS HWY, SUITE 103
29 PALMS CA
92277
US

IV. Provider business mailing address

7179 PALO ALTO #4
YUCCA VALLEY CA
92284
US

V. Phone/Fax

Practice location:
  • Phone: 760-367-5906
  • Fax:
Mailing address:
  • Phone: 760-365-9305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberCA 15832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: