Provider Demographics
NPI:1033664073
Name:BURNHAM, MARK (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 TWIN PEAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8515
Mailing Address - Country:US
Mailing Address - Phone:505-599-8613
Mailing Address - Fax:877-867-1749
Practice Address - Street 1:3500 TWIN PEAKS BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8515
Practice Address - Country:US
Practice Address - Phone:505-599-8613
Practice Address - Fax:877-867-1749
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-77826163W00000X
NM372972163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse