Provider Demographics
NPI:1073585329
Name:BURNS, GREGORY LEE (PA C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LEE
Last Name:BURNS
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 NW 84TH AVE
Mailing Address - Street 2:APT# 628
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1845
Mailing Address - Country:US
Mailing Address - Phone:954-270-7116
Mailing Address - Fax:
Practice Address - Street 1:2901 CORAL HILLS DR
Practice Address - Street 2:SUITE 150
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4146
Practice Address - Country:US
Practice Address - Phone:954-755-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
U6524ZMedicare ID - Type Unspecified
Q58440Medicare UPIN