Healthcare Provider Details

I. General information

NPI: 1033664073
Provider Name (Legal Business Name): MARK BURNHAM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 TWIN PEAKS BLVD
FARMINGTON NM
87401-8515
US

IV. Provider business mailing address

3500 TWIN PEAKS BLVD
FARMINGTON NM
87401-8515
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8613
  • Fax: 877-867-1749
Mailing address:
  • Phone: 505-599-8613
  • Fax: 877-867-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-77826
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number372972
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: