Provider Demographics
NPI:1053047092
Name:BURNS, GABRIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:BURNS
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N RENAISSANCE BLVD NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-7002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4150 REGENTS PARK ROW STE 345
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9102
Practice Address - Country:US
Practice Address - Phone:858-207-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64744208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty