Basic Information
| Provider Information | |||||||||
| NPI: | 1073550323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITHERRITE | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 SKYLINE DR | ||||||||
| Address2: | BOX 1519 | ||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986721519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094939533 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986720212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094932133 | ||||||||
| FaxNumber: | 5094939538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33240 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 46597 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD27358 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8456261 | 05 | WA | MEDICAID | P00332926 | 01 | WA | PTAN | OTHER | 271243 | 05 | OR | MEDICAID |