Healthcare Provider Details

I. General information

NPI: 1548775620
Provider Name (Legal Business Name): BURTON SURGICAL ASSISTANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 MIMS ST
FORT WORTH TX
76112-3454
US

IV. Provider business mailing address

1432 MIMS ST
FORT WORTH TX
76112-3454
US

V. Phone/Fax

Practice location:
  • Phone: 817-896-4882
  • Fax:
Mailing address:
  • Phone: 817-896-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number4842
License Number StateTX

VIII. Authorized Official

Name: ANDREA BURTON
Title or Position: SURGICAL ASSISTANT
Credential: PA-C
Phone: 817-896-4882