Provider Demographics
NPI:1689634156
Name:WHITESIDE, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 MONROEVILLE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-2525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4075 MONROEVILLE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-2525
Practice Address - Country:US
Practice Address - Phone:412-372-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062896L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001739456Medicaid
PA001739456Medicaid
PA029305Medicare ID - Type Unspecified