Provider Demographics
NPI:1861686065
Name:WHITENACK, PETER PAUL (PTA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:PAUL
Last Name:WHITENACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 COUNTY ROAD 3151
Mailing Address - Street 2:
Mailing Address - City:DE BERRY
Mailing Address - State:TX
Mailing Address - Zip Code:75639-3224
Mailing Address - Country:US
Mailing Address - Phone:903-766-2716
Mailing Address - Fax:903-766-2745
Practice Address - Street 1:340 COUNTY ROAD 3151
Practice Address - Street 2:
Practice Address - City:DE BERRY
Practice Address - State:TX
Practice Address - Zip Code:75639-3224
Practice Address - Country:US
Practice Address - Phone:903-766-2716
Practice Address - Fax:903-766-2745
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2034379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant