Provider Demographics
NPI:1760695514
Name:BURNHAM, BRUCE MCCLANAHAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:MCCLANAHAN
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11119 S PRESCOTT PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5098
Mailing Address - Country:US
Mailing Address - Phone:801-562-0058
Mailing Address - Fax:
Practice Address - Street 1:3152 NORTH UNIVERSITY AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-375-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1033258906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant