Provider Demographics
NPI:1265021539
Name:BURCHAM, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BURCHAM
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 1:2611 WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1833
Mailing Address - Country:US
Mailing Address - Phone:937-929-9085
Mailing Address - Fax:
Practice Address - Street 1:2611 WAYNE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1833
Practice Address - Country:US
Practice Address - Phone:937-929-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHAPRN.CNP.0037969363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator