Provider Demographics
NPI:1609162080
Name:WHITEHEAD, MARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:WHITEHEAD
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 1:7243 DELLA DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5104
Mailing Address - Country:US
Mailing Address - Phone:407-649-6878
Mailing Address - Fax:407-423-1380
Practice Address - Street 1:7243 DELLA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5104
Practice Address - Country:US
Practice Address - Phone:407-649-6878
Practice Address - Fax:407-423-1380
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106022363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004300300Medicaid