Provider Demographics
NPI:1932720877
Name:BURKHOLDER, BEAU R (MD)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:R
Last Name:BURKHOLDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 HIGH PLAINS CT
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-7718
Mailing Address - Country:US
Mailing Address - Phone:701-740-0593
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program