Provider Demographics
NPI:1053354068
Name:BURCKLE, JOHN W (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:BURCKLE
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-367-3360
Mailing Address - Fax:
Practice Address - Street 1:727 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1660
Practice Address - Country:US
Practice Address - Phone:502-367-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1227363A00000X
KYPA1008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100011930Medicaid
TN3663192Medicaid
TN4097067OtherBLUE CROSS
TN3663192Medicare PIN