Provider Demographics
NPI:1649527706
Name:BURRIS, RANDY
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BURRIS
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 1:139 LAKE HEAD RD
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28128-7607
Mailing Address - Country:US
Mailing Address - Phone:336-391-5874
Mailing Address - Fax:
Practice Address - Street 1:139 LAKE HEAD RD
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:NC
Practice Address - Zip Code:28128-7607
Practice Address - Country:US
Practice Address - Phone:336-391-5874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC216642163WM0705X
MARN2275155163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care