Provider Demographics
NPI:1164405114
Name:WHITAKER, KERRY (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W. KALEY STREET
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2931
Mailing Address - Country:US
Mailing Address - Phone:407-423-2581
Mailing Address - Fax:407-849-6470
Practice Address - Street 1:20 W. KALEY STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2931
Practice Address - Country:US
Practice Address - Phone:407-423-2581
Practice Address - Fax:407-849-6470
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA 484363A00000X
FLPAX00002031363AM0700X
FLPA3516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023753200Medicaid
FL290461600Medicaid