Provider Demographics
NPI:1336330562
Name:BURLESON, GREG EUGENE (NURSE)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:EUGENE
Last Name:BURLESON
Suffix:
Gender:M
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 W AVENUE K14
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-4903
Mailing Address - Country:US
Mailing Address - Phone:661-943-2997
Mailing Address - Fax:661-943-2997
Practice Address - Street 1:43423 DIVISION ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4639
Practice Address - Country:US
Practice Address - Phone:661-726-2850
Practice Address - Fax:661-726-2854
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171783164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse