Provider Demographics
NPI:1467400747
Name:BURNETT, GLENN EDWARD II (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EDWARD
Last Name:BURNETT
Suffix:II
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:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-2722
Mailing Address - Fax:307-733-9720
Practice Address - Street 1:555 E BROADWAY AVE STE 201
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-7222
Practice Address - Fax:307-733-9720
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11577A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY150006600Medicaid
TX1013146-03Medicaid
TX101314604Medicaid
TXP00251531Medicare PIN
TXTXB124052OtherMEDICARE
TX1013146-03Medicaid
TX8L27531Medicare PIN
TX8D7770Medicare PIN