Provider Demographics
NPI:1720451610
Name:WHITING, CARRIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:WHITING
Suffix:
Gender:F
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 1:1620 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3551
Mailing Address - Country:US
Mailing Address - Phone:707-439-4039
Mailing Address - Fax:
Practice Address - Street 1:1620 PENNSYLVANIA AVE STE E
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3551
Practice Address - Country:US
Practice Address - Phone:707-439-4039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant