Provider Demographics
NPI:1033822333
Name:BURDOLSKI, MARISA LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:LYNN
Last Name:BURDOLSKI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 NIEMAN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-2906
Mailing Address - Country:US
Mailing Address - Phone:913-515-7859
Mailing Address - Fax:
Practice Address - Street 1:5900 NIEMAN RD STE 300
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-2906
Practice Address - Country:US
Practice Address - Phone:913-515-7859
Practice Address - Fax:877-569-3050
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-81871-031363LF0000X
KSTMP-161320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1811955024Medicaid