Provider Demographics
NPI:1952152514
Name:BURGNER, SCOTT DANIEL
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DANIEL
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 1:1108 E HISTORIC HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5466
Mailing Address - Country:US
Mailing Address - Phone:505-726-9642
Mailing Address - Fax:505-726-9642
Practice Address - Street 1:1108 E HISTORIC HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5466
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:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NM32D2133123247ZC0005X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ210425Medicaid
1073138244OtherGROUP NPI
NM91159792Medicaid