Provider Demographics
NPI:1659351609
Name:WHITEHEAD, RICHARD A (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOCPAC SOJ07
Mailing Address - Street 2:BLD 20 RM 212
Mailing Address - City:CAMP H M SMITH
Mailing Address - State:HI
Mailing Address - Zip Code:96861-4046
Mailing Address - Country:US
Mailing Address - Phone:808-470-1082
Mailing Address - Fax:
Practice Address - Street 1:SOCPAC SOJ07
Practice Address - Street 2:BLD 20 RM 212
Practice Address - City:CAMP H M SMITH
Practice Address - State:HI
Practice Address - Zip Code:96861-4046
Practice Address - Country:US
Practice Address - Phone:808-470-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1070457363AM0700X
UT13217715-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical