Provider Demographics
NPI:1942677307
Name:BURNSIDE, HEATHER M (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:WINSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:420 WHITEHALL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-3299
Mailing Address - Country:US
Mailing Address - Phone:231-744-4743
Mailing Address - Fax:
Practice Address - Street 1:420 WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:NORTH MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-3299
Practice Address - Country:US
Practice Address - Phone:231-744-4743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007498363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical