=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881903680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MONTE CARL BURNAM PHYSICIAN ASSISTANT PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2010
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1145 E AMELIA DR
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-360-1864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1145 E AMELIA DR
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90807-2403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-360-1864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MONTE CARL BURNAM
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 323-360-1864
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA10764
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------