Provider Demographics
NPI:1760154389
Name:BURRIS, ROBERT WAYNE JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:BURRIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8055 N 65TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53223-3408
Mailing Address - Country:US
Mailing Address - Phone:414-881-1858
Mailing Address - Fax:
Practice Address - Street 1:8055 N 65TH ST
Practice Address - Street 2:
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53223-3408
Practice Address - Country:US
Practice Address - Phone:414-881-1858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIB620-7797-3121-06172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100008887Medicaid