Healthcare Provider Details

I. General information

NPI: 1922289024
Provider Name (Legal Business Name): ROBERT GLENN BURDINE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4TH & INNER LOOP
FT. IRWIN CA
92310-5109
US

IV. Provider business mailing address

PO BOX 3531
YUMA PROVING GROUND AZ
85365-0911
US

V. Phone/Fax

Practice location:
  • Phone: 928-328-3020
  • Fax:
Mailing address:
  • Phone: 928-328-3020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN134298
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: