Provider Demographics
NPI:1659027217
Name:WHIGHAM, MITCHELL (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:WHIGHAM
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 1:200 TARPON TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5287
Mailing Address - Country:US
Mailing Address - Phone:540-290-5584
Mailing Address - Fax:
Practice Address - Street 1:200 TARPON TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5287
Practice Address - Country:US
Practice Address - Phone:910-938-1114
Practice Address - Fax:910-938-1118
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115717363A00000X
NC0010-12270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant