Provider Demographics
NPI:1912002221
Name:WHITEHEAD, DOUGLAS A (PAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:A
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-238-2500
Mailing Address - Fax:
Practice Address - Street 1:2825 8TH AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0909
Practice Address - Country:US
Practice Address - Phone:406-238-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT353363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000095313OtherBCBS PIN
MT4302311OtherMDCD PIN
WY119700200OtherMDCD PIN
MT000095313OtherBCBS PIN
MT4302311OtherMDCD PIN
MT011001447Medicare PIN
WY119700200OtherMDCD PIN
MTQ07362Medicare UPIN