Provider Demographics
NPI:1578658605
Name:WHITEHEAD, CHRISTINE RENE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:RENE
Last Name:WHITEHEAD
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 1:1659 TAMARISK DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67230-7648
Mailing Address - Country:US
Mailing Address - Phone:316-440-5916
Mailing Address - Fax:
Practice Address - Street 1:1659 TAMARISK DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67230-7648
Practice Address - Country:US
Practice Address - Phone:316-440-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSR32001Medicare UPIN