Provider Demographics
NPI:1427506096
Name:BURG, JAMI NICOLE (PA)
Entity type:Individual
Prefix:
First Name:JAMI
Middle Name:NICOLE
Last Name:BURG
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 1:233 W WISCONSIN AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5227
Mailing Address - Country:US
Mailing Address - Phone:262-366-9141
Mailing Address - Fax:
Practice Address - Street 1:707 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3027
Practice Address - Country:US
Practice Address - Phone:920-219-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3889-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1427506096OtherCOMMERCIAL INSURANCES
WI1427506096Medicaid