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General NPI Number Information
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NPI Number | 1548775620
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Entity Type | Organization
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Legal Business Name | BURTON SURGICAL ASSISTANT
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Dates
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Enumeration Date | 12/11/2017
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Last Update Date | 12/11/2017
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Provider Practice Location Address
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Address Line | 1432 MIMS ST
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City | FORT WORTH
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State | TX
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Zip | 76112-3454
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Country | US
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Telephone | 817-896-4882
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Fax |
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Provider Business Mailing Address
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Address Line | 1432 MIMS ST
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City | FORT WORTH
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State | TX
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Zip | 76112-3454
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Country | US
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Telephone | 817-896-4882
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Fax |
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Authorized Official
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Title or Position | SURGICAL ASSISTANT
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Name | ANDREA BURTON
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Credential | PA-C
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Telephone | 817-896-4882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 4842
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License Number State | TX
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