Provider Demographics
NPI:1417511445
Name:ERMITUS, WITHMAN JAMES
Entity Type:Individual
Prefix:
First Name:WITHMAN
Middle Name:JAMES
Last Name:ERMITUS
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 1:12775 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-4648
Mailing Address - Country:US
Mailing Address - Phone:786-291-2914
Mailing Address - Fax:
Practice Address - Street 1:12775 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-4648
Practice Address - Country:US
Practice Address - Phone:786-291-2914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA57111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program