Provider Demographics
NPI:1821307448
Name:BURBANK, DUSTIN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:BURBANK
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-688-6100
Mailing Address - Fax:702-346-0801
Practice Address - Street 1:577 S RIVER RD
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2097
Practice Address - Country:US
Practice Address - Phone:435-688-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4723363AM0700X
UT9030601-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical