Provider Demographics
NPI:1205870649
Name:WHITAKER, LARRY KEITH JR (PA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:KEITH
Last Name:WHITAKER
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:801 E ORANGE ST
Practice Address - Street 2:HOOPESTON COMMUNITY MEMORIAL HOSPITAL DBA CHARLOTTE ANN
Practice Address - City:HOOPESTON
Practice Address - State:IL
Practice Address - Zip Code:60942-1802
Practice Address - Country:US
Practice Address - Phone:217-283-5644
Practice Address - Fax:217-283-7432
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002299363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096466OtherHEALTH ALLIANCE
IL085002299OtherLICENSE NUMBER
IL777561OtherHEALTH LINK
ILQ55235Medicare UPIN
IL777561OtherHEALTH LINK