Provider Demographics
NPI:1376576546
Name:BURMEISTER, DIANA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BURMEISTER
Suffix:
Gender:F
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 1:29275 NORTHWESTERN HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1044
Mailing Address - Country:US
Mailing Address - Phone:877-784-3667
Mailing Address - Fax:248-784-3743
Practice Address - Street 1:29275 NORTHWESTERN HWY
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1044
Practice Address - Country:US
Practice Address - Phone:877-784-3667
Practice Address - Fax:248-784-3743
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002920364SN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601002920OtherLICENSE
MIP36348Medicare UPIN
MI5601002920OtherLICENSE