Provider Demographics
NPI:1669663522
Name:BURGESS, CAROLE (PA)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 WILLIAMSON CT
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8164
Mailing Address - Country:US
Mailing Address - Phone:615-331-5536
Mailing Address - Fax:
Practice Address - Street 1:1805 WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-8164
Practice Address - Country:US
Practice Address - Phone:615-331-5536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA001179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant