Basic Information
| Provider Information | |||||||||
| NPI: | 1639492952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNSIDE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 81113 | ||||||||
| Address2: | ASHLEY RIVER STATION | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294161113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435730499 | ||||||||
| FaxNumber: | 8433886298 | ||||||||
| Practice Location | |||||||||
| Address1: | 1028 EWALL ST | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294643046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435730499 | ||||||||
| FaxNumber: | 8433886292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2010 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | TL 1511 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | TL 1511 | 01 | SC | SC STATE TEMP LICENSE | OTHER |