Provider Demographics
NPI:1730146754
Name:BURRELL, LANCE R (APRN)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:R
Last Name:BURRELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:
Practice Address - Street 1:EXIT 102 11/2 MI. SOUTH I-40
Practice Address - Street 2:ACOMA-CANONCITO-LAGUNA INDIAN
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049-0130
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5653727-4405363LF0000X
AZAP4694363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NMH3451Medicaid