Provider Demographics
NPI:1477737484
Name:WHITBECK, JOHN HENDRIAN (PAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:HENDRIAN
Last Name:WHITBECK
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 1:172 MT PLEASANT ROAD
Mailing Address - Street 2:NEWTOWN PROFESSIONAL CENTER
Mailing Address - City:NEWTWON
Mailing Address - State:CT
Mailing Address - Zip Code:06470
Mailing Address - Country:US
Mailing Address - Phone:203-426-8442
Mailing Address - Fax:
Practice Address - Street 1:172 MT PLEASANT ROAD
Practice Address - Street 2:NEWTOWN PROFESSIONAL CENTER
Practice Address - City:NEWTWON
Practice Address - State:CT
Practice Address - Zip Code:06470
Practice Address - Country:US
Practice Address - Phone:203-426-8442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002023OtherPA LICENSE