Provider Demographics
NPI:1881903680
Name:MONTE CARL BURNAM PHYSICIAN ASSISTANT PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MONTE CARL BURNAM PHYSICIAN ASSISTANT PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:323-360-1864
Mailing Address - Street 1:1145 E AMELIA DR
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2403
Mailing Address - Country:US
Mailing Address - Phone:323-360-1864
Mailing Address - Fax:
Practice Address - Street 1:1145 E AMELIA DR
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2403
Practice Address - Country:US
Practice Address - Phone:323-360-1864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10764363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SQ5778Medicare UPIN