Provider Demographics
NPI:1407814718
Name:BURRIS, WENDELL G (MD)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:G
Last Name:BURRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2370 CORPORATE CIR
Mailing Address - Street 2:STE 300
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7760
Mailing Address - Country:US
Mailing Address - Phone:702-910-3950
Mailing Address - Fax:702-778-2264
Practice Address - Street 1:100 N GREEN VALLEY PKWY STE 239
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7704
Practice Address - Country:US
Practice Address - Phone:702-844-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1407814718Medicaid
NVP00376332OtherRAILROAD MEDICARE
NVFZ151Y (CQ328B)Medicare PIN
NVFZ151Z (CQ328A)Medicare PIN
NV102502Medicare PIN
NV102502Medicare PIN
NVFZ151Y (CQ328B)Medicare PIN
NVP00376332OtherRAILROAD MEDICARE