Provider Demographics
NPI:1689759524
Name:WHETSELL, JIMMY DON (PA-C)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:DON
Last Name:WHETSELL
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 1:1511 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-4430
Mailing Address - Country:US
Mailing Address - Phone:940-767-0818
Mailing Address - Fax:940-767-0921
Practice Address - Street 1:1511 10TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4430
Practice Address - Country:US
Practice Address - Phone:940-767-0818
Practice Address - Fax:940-767-0921
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8166K2Medicare ID - Type UnspecifiedMEDICARE
TXP12783Medicare UPIN