=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649744558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN BURG MSN, APNP, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2019
-----------------------------------------------------
Last Update Date | 11/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E MORRISSEY DR
-----------------------------------------------------
City | ELKHORN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53121-4395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-723-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W5724 BONNER LN
-----------------------------------------------------
City | WALWORTH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53184-5951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-374-1779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 8904
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------