Provider Demographics
NPI:1790745446
Name:BURRIS, RICHARD WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:BURRIS
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 1:257 W SAINT GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7827
Mailing Address - Country:US
Mailing Address - Phone:715-463-5353
Mailing Address - Fax:
Practice Address - Street 1:257 W SAINT GEORGE AVE
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840
Practice Address - Country:US
Practice Address - Phone:715-463-5353
Practice Address - Fax:715-463-2753
Is Sole Proprietor?:No
Enumeration Date:2006-03-26
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4333-23363A00000X
MN9113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN449390700Medicaid