Provider Demographics
NPI:1740550078
Name:WHITLEY, CHESTER C ROBERT IV (PA-C)
Entity type:Individual
Prefix:
First Name:CHESTER
Middle Name:C ROBERT
Last Name:WHITLEY
Suffix:IV
Gender:
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 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:725-258-2982
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:4517 BLUE DIAMOND RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7620
Practice Address - Country:US
Practice Address - Phone:725-258-2982
Practice Address - Fax:877-709-4341
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1517363A00000X, 363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA1517OtherSTATE LICENSE
NVV72760OtherMEDICARE
NV1740550078Medicaid