Basic Information
| Provider Information | |||||||||
| NPI: | 1710942339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURSTEN | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2695 ROCKY MOUNTAIN AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805388702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5050 POWDERHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820094800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706341311 | ||||||||
| FaxNumber: | 9706341271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 42461 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7656A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 124242300 | 05 | WY | MEDICAID |