Provider Demographics
NPI:1487635579
Name:WHITAKER, KENT B (PA)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:B
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:STE R
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-755-9484
Mailing Address - Fax:435-755-2832
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:SUITE R
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-755-9484
Practice Address - Fax:435-755-2832
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105103-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP03187Medicare UPIN
UT000012278Medicare PIN