Provider Demographics
NPI:1992027510
Name:WRISTON, WHITNEY WAKEFIELD (PA-C)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:WAKEFIELD
Last Name:WRISTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:WAKEFIELD
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 WASHINGTON ST STE 105
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3181
Mailing Address - Country:US
Mailing Address - Phone:360-816-7380
Mailing Address - Fax:
Practice Address - Street 1:700 WASHINGTON ST STE 105
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-816-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60634564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60634564OtherPHYSICIAN ASSISTANT LICENSE
WA60634564OtherPHYSICIAN ASSISTANT LICENSE