Provider Demographics
NPI:1447214234
Name:WHITWORTH, JAN R (PAC)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:R
Last Name:WHITWORTH
Suffix:
Gender:F
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:PO BOX 1367
Mailing Address - Street 2:32 RAILROAD ST
Mailing Address - City:BETHEL
Mailing Address - State:ME
Mailing Address - Zip Code:04217
Mailing Address - Country:US
Mailing Address - Phone:207-824-2193
Mailing Address - Fax:207-824-0012
Practice Address - Street 1:32 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:ME
Practice Address - Zip Code:04217
Practice Address - Country:US
Practice Address - Phone:207-824-2193
Practice Address - Fax:207-824-0012
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME307160099Medicaid
ME307160099Medicaid
WHAP2366Medicare ID - Type Unspecified