Provider Demographics
NPI:1538636931
Name:WHALEY, MATTHEW RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:WHALEY
Suffix:
Gender:M
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 1:2415 N ORANGE AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5503
Mailing Address - Country:US
Mailing Address - Phone:407-303-2801
Mailing Address - Fax:407-303-2805
Practice Address - Street 1:2415 N ORANGE AVE STE 502
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5503
Practice Address - Country:US
Practice Address - Phone:407-303-2801
Practice Address - Fax:407-303-2805
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111739363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical