Provider Demographics
NPI:1912946542
Name:BURNS, MARK DOUGLAS (APRN, CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DOUGLAS
Last Name:BURNS
Suffix:
Gender:M
Credentials:APRN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E THIRD STREET
Mailing Address - Street 2:SSB-5
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3146
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI165395-30367500000X
MNR132680-6367500000X
MN1230367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN711178900Medicaid