Provider Demographics
NPI:1245657824
Name:BURRUS, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BURRUS
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:18780 INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-3593
Practice Address - Country:US
Practice Address - Phone:903-567-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX577526363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34479602Medicaid
TX775079OtherMEDICARE
TXP01454895OtherRAIL ROAD MEDICARE
TXP02207506OtherMEDICARE RAIL ROAD
TX344709601Medicaid
TX75-2616977-001OtherTRICARE
TX8055NPOtherBCBS