Provider Demographics
NPI:1629174123
Name:WHITENER, ROBERT G (PA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:G
Last Name:WHITENER
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 1:204 CHELSEA CT
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8173
Mailing Address - Country:US
Mailing Address - Phone:678-344-8700
Mailing Address - Fax:
Practice Address - Street 1:2878 FIVE FORKS TRICKUM RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5896
Practice Address - Country:US
Practice Address - Phone:678-344-8700
Practice Address - Fax:678-344-8600
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002074363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA002074OtherLICENSE
GA97WCDFLMedicare ID - Type Unspecified
GA002074OtherLICENSE