Provider Demographics
NPI:1639492952
Name:BURNSIDE, EDWARD CLARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CLARK
Last Name:BURNSIDE
Suffix:
Gender:M
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:PO BOX 81113
Mailing Address - Street 2:ASHLEY RIVER STATION
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29416-1113
Mailing Address - Country:US
Mailing Address - Phone:843-573-0499
Mailing Address - Fax:843-388-6298
Practice Address - Street 1:1028 EWALL ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3046
Practice Address - Country:US
Practice Address - Phone:843-573-0499
Practice Address - Fax:843-388-6292
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL 1511363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL 1511OtherSC STATE TEMP LICENSE