Healthcare Provider Details

I. General information

NPI: 1457433567
Provider Name (Legal Business Name): MONIQUE SUZANNE BURTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E STEVENS CIR
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-616-2495
  • Fax:
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberMD00045449
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: