Provider Demographics
NPI:1942715412
Name:BURT, SAMUEL O (CRNA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:O
Last Name:BURT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7746 S 164TH DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5836
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1139 E HIGH ST STE 203
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-4849
Practice Address - Country:US
Practice Address - Phone:434-817-8484
Practice Address - Fax:434-817-8490
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ240773367500000X
NH076895-21367500000X
VA0024190708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered