Provider Demographics
NPI:1972932986
Name:WHETTON, BRYAN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:WHETTON
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 1:982 W 540 S
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4743
Mailing Address - Country:US
Mailing Address - Phone:801-678-7889
Mailing Address - Fax:
Practice Address - Street 1:783 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2450
Practice Address - Country:US
Practice Address - Phone:360-577-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.60423331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant