Provider Demographics
NPI:1215021688
Name:BURNETT, JAMES R (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:R
Other - Last Name:BURNETT
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1400 E BOULDER ST STE 700
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-364-3278
Mailing Address - Fax:719-365-7668
Practice Address - Street 1:1400 E BOULDER ST STE 700
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-3278
Practice Address - Fax:719-365-7668
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99973Medicaid
NM99973Medicaid