Provider Demographics
NPI:1689010340
Name:BURKHARDT, CHARITY JOY (PA)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:JOY
Last Name:BURKHARDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHARITY
Other - Middle Name:JOY
Other - Last Name:BUCHANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3065 W SOUTHLAKE BLVD # 140
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6730
Practice Address - Country:US
Practice Address - Phone:817-380-5911
Practice Address - Fax:817-385-6579
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS0201078OtherDPS CERTIFICATE NUMBER
TXPA08610OtherSTATE LICENSE NUMBER