Healthcare Provider Details

I. General information

NPI: 1114365459
Provider Name (Legal Business Name): MICHAEL LEE BURTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER ROAD SUITE 200
MARIETTA GA
30060
US

IV. Provider business mailing address

PO BOX 102321
ATLANTA GA
30368-2321
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-7550
  • Fax: 770-514-1390
Mailing address:
  • Phone: 770-801-2500
  • Fax: 770-803-2121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006815
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: