Provider Demographics
NPI:1811469604
Name:BURNETT, MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:BURNETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W D.L INGRAM AV
Mailing Address - Street 2:
Mailing Address - City:CANNON AFB
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-904-5392
Mailing Address - Fax:
Practice Address - Street 1:104 W D.L INGRAM AV
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-904-5392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11690304-1206363A00000X, 363AM0700X
363A00000X
NMPA2024-0091363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant