Provider Demographics
NPI:1932753456
Name:WHITTAKER, SHAUGHN RANDALL
Entity Type:Individual
Prefix:MR
First Name:SHAUGHN
Middle Name:RANDALL
Last Name:WHITTAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2945
Mailing Address - Country:US
Mailing Address - Phone:321-842-9000
Mailing Address - Fax:321-843-6326
Practice Address - Street 1:1720 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2945
Practice Address - Country:US
Practice Address - Phone:321-842-9000
Practice Address - Fax:321-843-6326
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002533363LF0000X, 363LA2200X
CA95012121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily