Provider Demographics
NPI:1598182214
Name:BURNS, MATTHEW WHEATON (IDMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WHEATON
Last Name:BURNS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1255
Mailing Address - Country:US
Mailing Address - Phone:707-718-5028
Mailing Address - Fax:
Practice Address - Street 1:105 COLORADO ST
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1255
Practice Address - Country:US
Practice Address - Phone:707-718-5028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians