Provider Demographics
NPI:1225053218
Name:WHITEHEAD, MICHAEL B (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:WHITEHEAD
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 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:
Practice Address - Street 1:50 LEROY ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1786
Practice Address - Country:US
Practice Address - Phone:315-265-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005139-1363AM0700X
NC102358363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752990CMedicare ID - Type Unspecified
NCP16061Medicare UPIN
NYP16061Medicare UPIN