Basic Information
| Provider Information | |||||||||
| NPI: | 1720451610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITING | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1620 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945333551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074394039 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1620 PENNSYLVANIA AVE STE E | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945333551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074394039 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2015 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PT653 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.