Provider Demographics
NPI:1235326059
Name:WHITEHEAD, MARK A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:326 N LOCUST AVE
Mailing Address - Street 2:STE B
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-3516
Mailing Address - Country:US
Mailing Address - Phone:931-762-9797
Mailing Address - Fax:931-762-9798
Practice Address - Street 1:1222 TROTWOOD AVE.
Practice Address - Street 2:STE 108
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-388-8965
Practice Address - Fax:931-840-8520
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2017-02-13
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Provider Licenses
StateLicense IDTaxonomies
TN1531363A00000X
TNPA0000001531208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1501347Medicaid