Provider Demographics
NPI:1821007733
Name:BURNAM, TONETTE (PA)
Entity Type:Individual
Prefix:
First Name:TONETTE
Middle Name:
Last Name:BURNAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 AMEN CORNER RD
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5062
Mailing Address - Country:US
Mailing Address - Phone:512-787-6990
Mailing Address - Fax:
Practice Address - Street 1:3307 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4946
Practice Address - Country:US
Practice Address - Phone:866-872-8060
Practice Address - Fax:866-643-4165
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PA114040OtherBLUE SHIELD
CA00PA114040Medicaid
CA970022806OtherRAILROAD MEDICARE
CAP03013Medicare UPIN
CAWPA11404CMedicare ID - Type Unspecified