Provider Demographics
NPI:1194054841
Name:BURKETT, MAYA RAE (PA)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:RAE
Last Name:BURKETT
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 1:628 GREEN VALLEY RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:628 GREEN VALLEY RD
Practice Address - Street 2:SUITE 408
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7730
Practice Address - Country:US
Practice Address - Phone:336-315-5500
Practice Address - Fax:336-315-5553
Is Sole Proprietor?:No
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1090147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant