Healthcare Provider Details

I. General information

NPI: 1285621201
Provider Name (Legal Business Name): CHARLES CLIFTON BURROUGHS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL GUAM FARENHOLT AVE BLDG K-1
AGANA HEIGHTS GU
96910
US

IV. Provider business mailing address

999 S MARINE DR ALUPANG BEACH TOWER #401
TAMUNING GU
96913-3415
US

V. Phone/Fax

Practice location:
  • Phone: 671-644-9054
  • Fax:
Mailing address:
  • Phone: 671-649-9666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164796
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: