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General NPI Number Information
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NPI Number | 1134745664
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Entity Type | Individual
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Provider Name | CONNER J BURCK PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/20/2020
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Last Update Date | 02/21/2023
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Provider Practice Location Address
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Address Line | 500 W BROADWAY ST STE 320
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City | MISSOULA
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State | MT
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Zip | 59802-4003
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Country | US
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Telephone | 406-329-5615
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Fax | 406-329-5606
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Provider Business Mailing Address
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Address Line | PO BOX 12
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City | LIBERTY LAKE
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State | WA
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Zip | 99019-0012
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Country | US
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Telephone | 406-329-5615
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Fax | 406-329-5606
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA61100789
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | MED-PAC-LIC-115542
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License Number State | MT
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