Provider Demographics
NPI:1740500495
Name:BURGOA-RIO, CARLOS FERNANDO (PA-C)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:FERNANDO
Last Name:BURGOA-RIO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3555 SYCAMORE TRL APT 205
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6862
Mailing Address - Country:US
Mailing Address - Phone:336-776-0966
Mailing Address - Fax:
Practice Address - Street 1:2050 GRIFFITH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5509
Practice Address - Country:US
Practice Address - Phone:336-293-4510
Practice Address - Fax:336-293-4512
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-02248363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical