Provider Demographics
NPI:1063486264
Name:WHISENANT, ANN HAZEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:HAZEN
Last Name:WHISENANT
Suffix:
Gender:F
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 1:2500 MERCED ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4201
Mailing Address - Country:US
Mailing Address - Phone:510-454-1000
Mailing Address - Fax:925-215-2251
Practice Address - Street 1:2500 MERCED ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4201
Practice Address - Country:US
Practice Address - Phone:510-454-1000
Practice Address - Fax:925-215-2251
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11627363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR23396Medicare UPIN
CA0PA116271Medicare ID - Type UnspecifiedWITH SPA GROUP ID
CA0PA116270Medicare ID - Type UnspecifiedORIGINAL NUMBER