Provider Demographics
NPI:1265546485
Name:BURCH, J. BRIAN (PAC)
Entity type:Individual
Prefix:MR
First Name:J.
Middle Name:BRIAN
Last Name:BURCH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 SANTA CRUZ
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-8629
Mailing Address - Country:US
Mailing Address - Phone:361-727-7224
Mailing Address - Fax:
Practice Address - Street 1:1509 W LOOP 281
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2820
Practice Address - Country:US
Practice Address - Phone:903-759-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA028222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216652201Medicaid
TXTXB112110Medicare PIN
TX216652201Medicaid