Basic Information
| Provider Information | |||||||||
| NPI: | 1720463649 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WHITAKER | ||||||||
| FirstName: | BRIAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY # MC5136 | ||||||||
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| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589667711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589667711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 04/30/2018 | ||||||||
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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 | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 55166 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.