Provider Demographics
NPI:1275047466
Name:WHITNEY, CODY EVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:EVAN
Last Name:WHITNEY
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:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932-0277
Mailing Address - Country:US
Mailing Address - Phone:518-873-9000
Mailing Address - Fax:518-873-2314
Practice Address - Street 1:17 MILLER ROAD
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:NY
Practice Address - Zip Code:12928-2530
Practice Address - Country:US
Practice Address - Phone:518-597-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021661OtherNY LICENSE