Provider Demographics
NPI:1679012041
Name:BURRIS, MICHAEL LEE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:BURRIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MAREBLU STE 210
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3044
Mailing Address - Country:US
Mailing Address - Phone:949-831-1001
Mailing Address - Fax:
Practice Address - Street 1:26991 CROWN VALLEY PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6528
Practice Address - Country:US
Practice Address - Phone:949-582-5430
Practice Address - Fax:949-348-9513
Is Sole Proprietor?:No
Enumeration Date:2017-02-18
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily