Provider Demographics
NPI:1174833107
Name:WHITAKER MEDICAL
Entity Type:Organization
Organization Name:WHITAKER MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-318-6833
Mailing Address - Street 1:525 MADISON ST SE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4268
Mailing Address - Country:US
Mailing Address - Phone:866-830-9002
Mailing Address - Fax:
Practice Address - Street 1:525 MADISON ST SE
Practice Address - Street 2:SUITE 203
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4268
Practice Address - Country:US
Practice Address - Phone:866-830-9002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty