Healthcare Provider Details

I. General information

NPI: 1558034033
Provider Name (Legal Business Name): MARK DAVID BURNS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E VAUGHN AVE STE 104
RUSTON LA
71270-5975
US

IV. Provider business mailing address

2512 CEDAR CREEK DR
RUSTON LA
71270-2502
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2453
  • Fax:
Mailing address:
  • Phone: 859-227-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number221221
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: