Provider Demographics
NPI:1154069292
Name:WHARTON, JERRY WAYNE II
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
Last Name:WHARTON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:J.W.
Other - Middle Name:
Other - Last Name:WHARTON
Other - Suffix:II
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3145 S ATLANTIC AVE APT 1203
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-6274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:276-207-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant