Healthcare Provider Details

I. General information

NPI: 1265546485
Provider Name (Legal Business Name): J. BRIAN BURCH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 S KENTUCKY ST STE F600
AMARILLO TX
79102-2215
US

IV. Provider business mailing address

4811 BACLE RD
LONGVIEW TX
75604-9390
US

V. Phone/Fax

Practice location:
  • Phone: 806-373-2200
  • Fax:
Mailing address:
  • Phone: 903-699-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA028222
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: