Provider Demographics
NPI:1639129729
Name:BURNAM, MONTE CARL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MONTE
Middle Name:CARL
Last Name:BURNAM
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 1:1145 AMELIA DR.
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807
Mailing Address - Country:US
Mailing Address - Phone:818-528-2500
Mailing Address - Fax:818-528-2505
Practice Address - Street 1:16260 VENTURA BLVD
Practice Address - Street 2:140
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2203
Practice Address - Country:US
Practice Address - Phone:818-528-2500
Practice Address - Fax:818-528-2505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA10764EMedicare ID - Type Unspecified
CAS05778Medicare UPIN