Provider Demographics
NPI:1982893319
Name:WHITNEY, BRUCE BENJAMINE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:BENJAMINE
Last Name:WHITNEY
Suffix:
Gender:M
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-0001
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1540 S TAMIAMI TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2921
Practice Address - Country:US
Practice Address - Phone:941-917-8791
Practice Address - Fax:941-917-8793
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102589363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS970000095OtherMEDICARE PROVIDER NO
MO1982893319Medicaid
KS200597730 AMedicaid
ALR61343Medicare UPIN
KS200597730 AMedicaid
MOP00679186Medicare PIN
AS970000095OtherMEDICARE PROVIDER NO