Healthcare Provider Details

I. General information

NPI: 1700106218
Provider Name (Legal Business Name): SARA BURCHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S RIO GRANDE AVE
AZTEC NM
87410-2260
US

IV. Provider business mailing address

2577 MAIN AVE
DURANGO CO
81301-5919
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-2664
  • Fax: 505-334-7759
Mailing address:
  • Phone: 970-247-8382
  • Fax: 970-512-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA06228
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0005385
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2018-0040
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: