Provider Demographics
NPI:1366540221
Name:BURDO, DANIELLE (PA)
Entity type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:
Last Name:BURDO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 BOYLSTON ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2503
Mailing Address - Country:US
Mailing Address - Phone:617-277-1205
Mailing Address - Fax:
Practice Address - Street 1:830 BOYLSTON ST
Practice Address - Street 2:SUITE 106
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2503
Practice Address - Country:US
Practice Address - Phone:617-277-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00164500363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ73341Medicare UPIN
NJ105015BW0Medicare PIN