Provider Demographics
NPI:1255405379
Name:WHITWELL, BRUCE (PA)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:WHITWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0711
Mailing Address - Country:US
Mailing Address - Phone:903-791-9355
Mailing Address - Fax:903-831-7273
Practice Address - Street 1:3515 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0711
Practice Address - Country:US
Practice Address - Phone:903-791-9355
Practice Address - Fax:903-831-7273
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS43553Medicare UPIN