Provider Demographics
NPI:1255519708
Name:BURN, JENNIFER LANE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LANE
Last Name:BURN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 TILGHMAN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-6063
Mailing Address - Country:US
Mailing Address - Phone:910-891-4202
Mailing Address - Fax:
Practice Address - Street 1:721 TILGHMAN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-6063
Practice Address - Country:US
Practice Address - Phone:910-891-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10012133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102672Medicaid
NC2759066Medicare PIN