Provider Demographics
NPI:1407866387
Name:BURKS, GARRY WAYNE (PA)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:WAYNE
Last Name:BURKS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2861
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38557-2861
Mailing Address - Country:US
Mailing Address - Phone:931-863-5095
Mailing Address - Fax:931-863-3530
Practice Address - Street 1:6845 S YORK HWY
Practice Address - Street 2:
Practice Address - City:CLARKRANGE
Practice Address - State:TN
Practice Address - Zip Code:38553-5154
Practice Address - Country:US
Practice Address - Phone:931-863-5095
Practice Address - Fax:931-863-3530
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA454363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3104164OtherBLUE CROSS BLUE SHEILD TN
TN3667464Medicare ID - Type Unspecified
TN3104164OtherBLUE CROSS BLUE SHEILD TN