Healthcare Provider Details

I. General information

NPI: 1023380110
Provider Name (Legal Business Name): WILLIAM F BURNSIDE C.S.F.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8803 S 101ST EAST AVE STE 320
TULSA OK
74133-5726
US

IV. Provider business mailing address

8803 S 101ST EAST AVE STE 320
TULSA OK
74133-5726
US

V. Phone/Fax

Practice location:
  • Phone: 918-294-8000
  • Fax: 918-392-5648
Mailing address:
  • Phone: 918-294-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number120934
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number120934
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: