Provider Demographics
NPI:1710130190
Name:BURDMAN, ETHAN DAVID (PA-C, MPAS)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:DAVID
Last Name:BURDMAN
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:SD
Mailing Address - Zip Code:57442-1420
Mailing Address - Country:US
Mailing Address - Phone:206-679-4703
Mailing Address - Fax:
Practice Address - Street 1:608 E GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:SD
Practice Address - Zip Code:57442-1325
Practice Address - Country:US
Practice Address - Phone:605-765-2273
Practice Address - Fax:605-765-3212
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0692363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0692OtherSOUTH DAKOTA STATE LICENSE