Provider Demographics
NPI:1407418171
Name:BURBAGE, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BURBAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 WYNHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-7182
Mailing Address - Country:US
Mailing Address - Phone:334-320-6960
Mailing Address - Fax:
Practice Address - Street 1:1845 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36107-2613
Practice Address - Country:US
Practice Address - Phone:334-420-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-073713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine