Healthcare Provider Details

I. General information

NPI: 1467457440
Provider Name (Legal Business Name): MATTHEW J BURNETT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 FLY ROAD STE 200
EAST SYRACUSE NY
13057
US

IV. Provider business mailing address

6620 FLY ROAD STE 200
EAST SYRACUSE NY
13057
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4472
  • Fax:
Mailing address:
  • Phone: 315-464-4472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number009606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: