Provider Demographics
NPI:1508467051
Name:WITHERITE, JANENE CALDWELL (PA-C)
Entity Type:Individual
Prefix:
First Name:JANENE
Middle Name:CALDWELL
Last Name:WITHERITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 STELLAR END RD
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-4973
Mailing Address - Country:US
Mailing Address - Phone:307-690-4683
Mailing Address - Fax:
Practice Address - Street 1:1077 STELLAR END RD
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-4973
Practice Address - Country:US
Practice Address - Phone:307-690-4683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1943208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice