Healthcare Provider Details

I. General information

NPI: 1295484988
Provider Name (Legal Business Name): TYSON SCOTT BURNHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S STE 400
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S STE 400
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5691
  • Fax:
Mailing address:
  • Phone: 714-456-5691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA188398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: