Healthcare Provider Details

I. General information

NPI: 1659627586
Provider Name (Legal Business Name): JAMES LEE BURRUP PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. FORT ST. # 111
BOISE ID
83702
US

IV. Provider business mailing address

13153 W PAINT DR
BOISE ID
83713-1928
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-918-2336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-991
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: