Provider Demographics
NPI:1124117163
Name:BURBANK, JILL (PA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:BURBANK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W BROADWAY
Mailing Address - Street 2:PO BOX 309
Mailing Address - City:STAFFORD
Mailing Address - State:KS
Mailing Address - Zip Code:67578
Mailing Address - Country:US
Mailing Address - Phone:620-234-6826
Mailing Address - Fax:620-234-5014
Practice Address - Street 1:802 W BROADWAY
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:KS
Practice Address - Zip Code:67578
Practice Address - Country:US
Practice Address - Phone:620-234-6826
Practice Address - Fax:620-234-5014
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS426817OtherBLUE CROSS BLUE SHIELD
KS200306410AMedicaid
KS426817OtherBLUE CROSS BLUE SHIELD