Provider Demographics
NPI:1912977372
Name:BURSON, LYNNE VIRGINIA (CNM)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:VIRGINIA
Last Name:BURSON
Suffix:
Gender:F
Credentials:CNM
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 268838
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126
Mailing Address - Country:US
Mailing Address - Phone:918-660-3632
Mailing Address - Fax:918-660-3631
Practice Address - Street 1:4444 E 41ST ST
Practice Address - Street 2:3RD FLOOR STE B
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2527
Practice Address - Country:US
Practice Address - Phone:918-619-4200
Practice Address - Fax:918-619-4216
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0063474367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100010150AMedicaid
Q14307Medicare UPIN
OK100010150AMedicaid