Provider Demographics
NPI:1881449668
Name:DE JESUS BURGOS, LUIS ERNESTO (PA)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ERNESTO
Last Name:DE JESUS BURGOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC05BOX5452
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767
Mailing Address - Country:US
Mailing Address - Phone:939-335-5478
Mailing Address - Fax:
Practice Address - Street 1:300C CALLE FONT MARTELO
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3230
Practice Address - Country:US
Practice Address - Phone:787-465-5603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant