Provider Demographics
NPI:1528124336
Name:BURLESON, NANCY L (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:L
Last Name:BURLESON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N SARAH DEWITT DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3311
Mailing Address - Country:US
Mailing Address - Phone:830-672-8502
Mailing Address - Fax:830-672-8481
Practice Address - Street 1:834 W MEETING ST STE E
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6220
Practice Address - Country:US
Practice Address - Phone:803-285-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9271207V00000X
NC2014-01981207V00000X
TXH1875207V00000X
SC81745207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH1875OtherTEXAS STATE LI
NH30007675Medicaid
NH01Y008944NH01OtherANTHEM BCBS
NH3845503OtherAETNA
NH4350571OtherCIGNA
NHAA66543OtherHPHC
NHE58681Medicare UPIN
TXH1875OtherTEXAS STATE LI
NH30007675Medicaid