Provider Demographics
NPI:1871179689
Name:WHITTAKER, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9353 SE ALANSA DR STE C
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8579
Mailing Address - Country:US
Mailing Address - Phone:503-867-2253
Mailing Address - Fax:
Practice Address - Street 1:9353 SE ALANSA DR STE C
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8579
Practice Address - Country:US
Practice Address - Phone:503-867-2253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor