Basic Information
| Provider Information | |||||||||
| NPI: | 1679012041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURRIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 MAREBLU STE 210 | ||||||||
| Address2: | |||||||||
| City: | ALISO VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926563044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498311001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26991 CROWN VALLEY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495825430 | ||||||||
| FaxNumber: | 9493489513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2017 | ||||||||
| LastUpdateDate: | 03/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95006035 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.