Provider Demographics
NPI:1740900927
Name:BURNHAM, JONATHAN TYLER (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLER
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N ALAFAYA TRL STE 900
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4737
Mailing Address - Country:US
Mailing Address - Phone:407-629-2444
Mailing Address - Fax:407-643-2804
Practice Address - Street 1:1900 N ALAFAYA TRL STE 900
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4737
Practice Address - Country:US
Practice Address - Phone:407-629-2444
Practice Address - Fax:407-643-2804
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
FLPA9116438363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116706300Medicaid