Provider Demographics
NPI:1518190982
Name:BURRIS, ANTHONY (LAC)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:BURRIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S FITNESS PL
Mailing Address - Street 2:STE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 S FITNESS PL
Practice Address - Street 2:STE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6552
Practice Address - Country:US
Practice Address - Phone:208-938-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-221171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010174226OtherREGENCE BLUE SHIELD OF IDAHO