Provider Demographics
NPI:1619935053
Name:WHITEHEAD, JOHN A (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WHITEHEAD
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 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-429-8180
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 101
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-4366
Practice Address - Fax:801-429-8191
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3694731206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS70943OtherUPIN
UT870281028000Medicaid