Provider Demographics
NPI:1952152514
Name:BURGNER, SCOTT
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:BURGNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E COAL AVE
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-6006
Mailing Address - Country:US
Mailing Address - Phone:505-726-9642
Mailing Address - Fax:505-726-9642
Practice Address - Street 1:600 E COAL AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6006
Practice Address - Country:US
Practice Address - Phone:505-726-9642
Practice Address - Fax:505-726-9642
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM32D2133123247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073138244OtherGROUP NPI