Provider Demographics
NPI:1992803043
Name:BURNHAM, KEVIN WALTER (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:WALTER
Last Name:BURNHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:SC
Mailing Address - Zip Code:29697-1925
Mailing Address - Country:US
Mailing Address - Phone:864-847-6020
Mailing Address - Fax:
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:SC
Practice Address - Zip Code:29697-1925
Practice Address - Country:US
Practice Address - Phone:864-847-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 1049FP363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC 1049FPOtherMEDICAL PRACTICE/RX