Provider Demographics
NPI:1205032703
Name:BURSAW, ANDREW (DO)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BURSAW
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W ENT AVE
Mailing Address - Street 2:
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1595
Mailing Address - Country:US
Mailing Address - Phone:195-565-5877
Mailing Address - Fax:
Practice Address - Street 1:110 W ENT AVE
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1595
Practice Address - Country:US
Practice Address - Phone:719-556-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00592452084N0400X, 2084N0400X
NE6512084V0102X
MT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program