Provider Demographics
NPI:1891893558
Name:BURNETT, SEAN DEVON (PA)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:DEVON
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 VAN WYCK EXPY
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2897
Mailing Address - Country:US
Mailing Address - Phone:718-206-6070
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:8900 VAN WYCK EXPY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2897
Practice Address - Country:US
Practice Address - Phone:718-206-6070
Practice Address - Fax:718-206-6085
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NYP59186Medicare UPIN
NY00246075Medicaid