Provider Demographics
NPI:1821179367
Name:BURROUGHS, COLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:BURROUGHS
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 1:925 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2203
Mailing Address - Country:US
Mailing Address - Phone:847-234-1177
Mailing Address - Fax:847-234-1875
Practice Address - Street 1:925 SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2203
Practice Address - Country:US
Practice Address - Phone:847-234-1177
Practice Address - Fax:847-234-1875
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1052848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNVAD000Medicare UPIN