Healthcare Provider Details

I. General information

NPI: 1992117436
Provider Name (Legal Business Name): BEAU MICHAEL BURTON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E VAUGHN AVE
RUSTON LA
71270-5950
US

IV. Provider business mailing address

4075 COPPER RIDGE DR
TRAVERSE CITY MI
49684-7059
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN132815
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP07805
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07805
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: