Provider Demographics
NPI:1659627586
Name:BURRUP, JAMES LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:LEE
Last Name:BURRUP
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13153 W PAINT DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1928
Mailing Address - Country:US
Mailing Address - Phone:208-918-2336
Mailing Address - Fax:
Practice Address - Street 1:500 W. FORT ST.
Practice Address - Street 2:# 111
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:208-422-1319
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant