Provider Demographics
NPI:1386014116
Name:BURNS, RUSTY SCOTT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSTY
Middle Name:SCOTT
Last Name:BURNS
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 1:1560 W VIVANTE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-8202
Mailing Address - Country:US
Mailing Address - Phone:801-910-8641
Mailing Address - Fax:
Practice Address - Street 1:4745 SOUTH 3200 WEST
Practice Address - Street 2:OQUIRRH VIEW CLINIC
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129
Practice Address - Country:US
Practice Address - Phone:801-910-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9540934-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant