Provider Demographics
NPI:1174551022
Name:BURNHAM, BLAZE J (ARNP)
Entity type:Individual
Prefix:
First Name:BLAZE
Middle Name:J
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13607 E SPRAGUE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206
Mailing Address - Country:US
Mailing Address - Phone:509-892-3113
Mailing Address - Fax:509-892-3663
Practice Address - Street 1:13607 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0809
Practice Address - Country:US
Practice Address - Phone:509-892-3113
Practice Address - Fax:509-892-3663
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0946290001Medicare NSC
WAS59121Medicare UPIN
WAGAB04906Medicare PIN