Provider Demographics
NPI:1407616766
Name:WHITEMAN, PHORNPHIPHAT
Entity Type:Individual
Prefix:
First Name:PHORNPHIPHAT
Middle Name:
Last Name:WHITEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 PINTAIL LN STE 722
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-7816
Mailing Address - Country:US
Mailing Address - Phone:717-449-4916
Mailing Address - Fax:
Practice Address - Street 1:48 S MARKET ST STE 210
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2330
Practice Address - Country:US
Practice Address - Phone:717-449-4916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG013003225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist