Provider Demographics
NPI:1245938232
Name:BURLISON, NOAH PAUL
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:PAUL
Last Name:BURLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 CANDLE WOOD CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-7246
Mailing Address - Country:US
Mailing Address - Phone:630-303-3261
Mailing Address - Fax:
Practice Address - Street 1:2051 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-8863
Practice Address - Country:US
Practice Address - Phone:815-467-1254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist