Provider Demographics
NPI:1982898532
Name:WITOVER, GARY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:WITOVER
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 1:14583 HANSEL AVE
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-6362
Mailing Address - Country:US
Mailing Address - Phone:530-387-3775
Mailing Address - Fax:
Practice Address - Street 1:14583 HANSEL AVE
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-6362
Practice Address - Country:US
Practice Address - Phone:530-387-3775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant