MEDICARE: TYSON SCOTT BURNHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		NM
2	207R00000X	Internal Medicine Physician	A188398	CA

General Provider Information

NPI Number	:	1295484988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYSON SCOTT BURNHAM

Provider Business Mailing Address
First Line	:	101 THE CITY DR S STE 400
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-3201
Country	:	US
Telephone Number	:	714-456-5691
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 THE CITY DR S STE 400
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-3201
Country	:	US
Telephone Number	:	714-456-5691
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/19/2026

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