Provider Demographics
NPI:1992003180
Name:BURBANK, PAM MARIE (RN)
Entity Type:Individual
Prefix:
First Name:PAM
Middle Name:MARIE
Last Name:BURBANK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2045
Mailing Address - Country:US
Mailing Address - Phone:541-266-1209
Mailing Address - Fax:541-266-4515
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-266-1209
Practice Address - Fax:541-266-4515
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084053617RN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000WFBTVOtherNBMC GROUP MEDICARE NUMBER
OR1407812365OtherNBMC GROUP NPI
OR930635514OtherNBMC GROUP TAX ID FOR BILLING