Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | 12233 | FL |
N | 207YS0123X | Facial Plastic Surgeon | 13757 | NC |
NPI | 1750661328 |
---|---|
Provider Name | Dr. Jesse Andrew Burnam |
First Address | Fort Myers, FL 33912-3904 |
Second Address | Fort Myers, FL 33912-3904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2011 |
Last Update Date | 26/08/2011 |