Provider Demographics
NPI:1275074106
Name:WHALEN, MICHAEL EDWARD
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:WHALEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 CHALLISFORD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-2627
Mailing Address - Country:US
Mailing Address - Phone:706-614-8689
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program