Basic Information
| Provider Information | |||||||||
| NPI: | 1245657824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURRUS | ||||||||
| FirstName: | ANGELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18780 INTERSTATE 20 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035674841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2014 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 577526 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 34479602 | 05 | TX | MEDICAID | 775079 | 01 | TX | MEDICARE | OTHER | P01454895 | 01 | TX | RAIL ROAD MEDICARE | OTHER | P02207506 | 01 | TX | MEDICARE RAIL ROAD | OTHER | 344709601 | 05 | TX | MEDICAID | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 8055NP | 01 | TX | BCBS | OTHER |