Healthcare Provider Details

I. General information

NPI: 1851337299
Provider Name (Legal Business Name): RUSTY BURRESS P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CONNECTICUT AVE S
SARTELL MN
56377
US

IV. Provider business mailing address

1901 CONNECTICUT AVE S
SARTELL MN
56377
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-4100
  • Fax: 320-259-8044
Mailing address:
  • Phone: 320-259-4100
  • Fax: 320-259-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9618
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: