Basic Information
| Provider Information | |||||||||
| NPI: | 1164920344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | MIYO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2180 N MONTE VISTA DR | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996458850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077265330 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16941 N EAGLE RIVER LOOP RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077265330 | ||||||||
| FaxNumber: | 9077265330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2018 | ||||||||
| LastUpdateDate: | 01/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | RBT-18-2064 | 01 | AK | TRICARE | OTHER |