Healthcare Provider Details

I. General information

NPI: 1649057514
Provider Name (Legal Business Name): CASSIDY BURON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 UNSER BLVD SE
RIO RANCHO NM
87124-3392
US

IV. Provider business mailing address

6555 BASKET WEAVER AVE NW
ALBUQUERQUE NM
87114-6108
US

V. Phone/Fax

Practice location:
  • Phone: 505-253-7878
  • Fax:
Mailing address:
  • Phone: 808-683-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2023-0261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: