Basic Information
Provider Information | |||||||||
NPI: | 1538393244 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURKE | ||||||||
FirstName: | JOCELYN | ||||||||
MiddleName: | FAE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3016 W CHARLESTON BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891021973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027807118 | ||||||||
FaxNumber: | 7028954014 | ||||||||
Practice Location | |||||||||
Address1: | 1707 W CHARLESTON BLVD STE 160 | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891022354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7026715150 | ||||||||
FaxNumber: | 7023846493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2009 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208600000X | A149257 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | DR0061462 | CO | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.