Provider Demographics
NPI:1689010340
Name:BURKHARDT, CHARITY JOY (PA)
Entity Type:Individual
Prefix:
First Name:CHARITY
Middle Name:JOY
Last Name:BURKHARDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:JOY
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6 DOCTOR CIR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-5050
Mailing Address - Country:US
Mailing Address - Phone:903-757-3881
Mailing Address - Fax:903-757-5948
Practice Address - Street 1:1038 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2044
Practice Address - Country:US
Practice Address - Phone:903-593-9474
Practice Address - Fax:903-593-9477
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA08610OtherSTATE LICENSE NUMBER
TXS0201078OtherDPS CERTIFICATE NUMBER