Richard Wayne Burris, PA-C
Individual provider Active NPI Physician Assistant · Grantsburg, WI
NPI 1790745446 · NPPES record last updated Jun 19, 2018
Key facts
- NPI
- 1790745446
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physician Assistant 363A00000X
- License
- 4333-23 (WI)
- Practice address
- 257 W Saint George Ave
Grantsburg, WI 54840 - Phone
- (715) 463-5353
- Fax
- (715) 463-2753
- NPI assigned
- Mar 26, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 4
Hospital & facility affiliations 1
Medicare Care Compare profile
- Specialty
- Physician Assistant
- Education
- Other, 1984
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Suburban Emergency Associates PA
Practice addresses (Care Compare)
1455 Saint Francis Ave
Shakopee, MN 55379-3374
Phone (952) 428-3000
Hospital & facility affiliations
- St Francis Regional Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20080104000540 | MN | Practitioner - Physician Assistant | 8426138363 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 4333-23 | WI | MD | Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Park Nicollet Clinic | Current |
Accepting new patients | |
| Park Nicollet Clinic | Current |
Accepting new patients |
Locations
5320 Hyland Greens Dr
Minneapolis, MN 55437
Phone (952) 993-2400
3850 Park Nicollet Blvd
St Louis Park, MN 55416
Phone (952) 883-1000
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 4333-23 | WI | Yes |
| Physician Assistant | 363A00000X | 9113 | MN |
Addresses
Primary practice location
257 W Saint George Ave
Grantsburg, WI 54840
Mailing address
257 W Saint George Ave
Grantsburg, WI 54840-7827
Phone (715) 463-5353
Other practice location 1
3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 449390700 | Medicaid | MN |
Other providers in Grantsburg, WI
- Burnett Medical Center Inc
- Burnett Medical Center Inc
- Burnett Medical Center Inc
- Burnett Medical Center Inc
- Burnett Medical Center Inc
- Kayla Carlson
- Richelle Christianson
- Trista Deloris Clemmer
- Abigail Dewitt
- Melinda Alice Deye
All providers in Grantsburg, WI · Physician Assistant in Wisconsin
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 19, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.