Provider Demographics
NPI:1164730289
Name:WETHERALL, IAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:WETHERALL
Suffix:
Gender:M
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 1:455 PINELLAS ST STE 320
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3369
Mailing Address - Country:US
Mailing Address - Phone:727-446-2273
Mailing Address - Fax:727-441-4966
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:SUITE 320
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3354
Practice Address - Country:US
Practice Address - Phone:727-446-2273
Practice Address - Fax:727-441-4966
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108763363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015310600Medicaid
FLY0S8ROtherBLUE CROSS BLUE SHIELD