Provider Demographics
NPI:1235112418
Name:BURNHAM, B GEOFFREY (PA-C)
Entity Type:Individual
Prefix:
First Name:B
Middle Name:GEOFFREY
Last Name:BURNHAM
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 1:324 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-1735
Mailing Address - Country:US
Mailing Address - Phone:860-739-6953
Mailing Address - Fax:860-739-2523
Practice Address - Street 1:324 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1735
Practice Address - Country:US
Practice Address - Phone:860-739-6953
Practice Address - Fax:860-739-2523
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS50256Medicare UPIN