Healthcare Provider Details

I. General information

NPI: 1083270458
Provider Name (Legal Business Name): MATTHEW BURNHAM FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2019
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6467 WOODLANDS PKWY
THE WOODLANDS TX
77381-3616
US

IV. Provider business mailing address

30 W GREENVINE CT
SPRING TX
77382-1699
US

V. Phone/Fax

Practice location:
  • Phone: 713-461-2915
  • Fax:
Mailing address:
  • Phone: 281-203-9921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP140798
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: