Healthcare Provider Details

I. General information

NPI: 1699100255
Provider Name (Legal Business Name): PAUL E. BURRIS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E 19TH ST
MOUNTAIN GROVE MO
65711-1114
US

IV. Provider business mailing address

500 E 19TH ST
MOUNTAIN GROVE MO
65711-1114
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-6563
  • Fax:
Mailing address:
  • Phone: 417-926-6563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA003962
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: