Provider Demographics
NPI:1831668235
Name:BURKS, BREANNE LOUISE
Entity Type:Individual
Prefix:MS
First Name:BREANNE
Middle Name:LOUISE
Last Name:BURKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 CLAFLIN RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-4614
Mailing Address - Country:US
Mailing Address - Phone:816-383-1410
Mailing Address - Fax:
Practice Address - Street 1:1129 CLAFLIN RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-4614
Practice Address - Country:US
Practice Address - Phone:816-383-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00000207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000OtherN/A