Provider Demographics
NPI:1346259298
Name:WHITING, JOEL B (PAC)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:B
Last Name:WHITING
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 WASHINGTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7592
Mailing Address - Country:US
Mailing Address - Phone:208-522-6662
Mailing Address - Fax:208-522-0880
Practice Address - Street 1:3300 WASHINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7592
Practice Address - Country:US
Practice Address - Phone:208-522-6662
Practice Address - Fax:208-522-0880
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAF74OtherBLUE CROSS OF IDAHO
ID000010163120OtherBLUE SHIELD OF IDAHO
IDPAF74OtherBLUE CROSS OF IDAHO
ID000010163120OtherBLUE SHIELD OF IDAHO