Provider Demographics
NPI:1154483865
Name:BURNSIDE, KATHERINE KEELY (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KEELY
Last Name:BURNSIDE
Suffix:
Gender:F
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 1:1 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2239
Mailing Address - Country:US
Mailing Address - Phone:304-473-2066
Mailing Address - Fax:304-472-0533
Practice Address - Street 1:1 AMALIA DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2239
Practice Address - Country:US
Practice Address - Phone:304-473-2066
Practice Address - Fax:304-472-0533
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBUPA83601Medicare PIN