Provider Demographics
NPI:1881667624
Name:BURLESON, TINA MICHELLE (MD)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:MICHELLE
Last Name:BURLESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1321 OBERLIN RD
Mailing Address - Street 2:A
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2052
Mailing Address - Country:US
Mailing Address - Phone:919-828-4747
Mailing Address - Fax:919-828-6765
Practice Address - Street 1:1321 OBERLIN RD
Practice Address - Street 2:A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2052
Practice Address - Country:US
Practice Address - Phone:919-828-4747
Practice Address - Fax:919-828-6765
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC200200460208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131JXMedicaid
NCH39362Medicare UPIN