Provider Demographics
NPI:1700179199
Name:BURNHAM, RUSSELL ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ADAM
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:P-10506 EUPHRATES RIVER VALLEY ROAD
Mailing Address - Street 2:1-89 CAV
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-774-0024
Mailing Address - Fax:315-772-6788
Practice Address - Street 1:P-10506 EUPHRATES RIVER VALLEY RD
Practice Address - Street 2:1-89 CAV, 2BCT, 10TH MTN DIV
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5438
Practice Address - Country:US
Practice Address - Phone:315-774-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2012-08-30
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant