Provider Demographics
NPI:1902580400
Name:BURNSIDE, GARRETT JAMES (MSC, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:JAMES
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:MSC, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 IRWIN ST APT D2
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2872
Mailing Address - Country:US
Mailing Address - Phone:304-514-1633
Mailing Address - Fax:
Practice Address - Street 1:943 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2812
Practice Address - Country:US
Practice Address - Phone:304-599-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0018822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer