Provider Demographics
NPI:1710020151
Name:BURLISON, BOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BOB
Middle Name:
Last Name:BURLISON
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 1:804 W ENID AVE
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-2248
Mailing Address - Country:US
Mailing Address - Phone:580-239-0449
Mailing Address - Fax:
Practice Address - Street 1:1590 W LIBERTY RD
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-1701
Practice Address - Country:US
Practice Address - Phone:580-889-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant