Provider Demographics
NPI:1629011754
Name:WERNER, WHITNEY M (PA)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:M
Last Name:WERNER
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 1:3304 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-7102
Mailing Address - Country:US
Mailing Address - Phone:707-725-9383
Mailing Address - Fax:707-725-1140
Practice Address - Street 1:3304 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-7102
Practice Address - Country:US
Practice Address - Phone:707-725-9383
Practice Address - Fax:707-725-1140
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2158841206363A00000X
CAPA52150363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT981727OtherNATIONAL COMMISSION
UTMW0329210OtherDEA
UTMW0329210OtherDEA
UT5166950001Medicare NSC
UT000055905Medicare PIN