Healthcare Provider Details

I. General information

NPI: 1629011754
Provider Name (Legal Business Name): WHITNEY M WERNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 RENNER DR
FORTUNA CA
95540-7102
US

IV. Provider business mailing address

3304 RENNER DR
FORTUNA CA
95540-7102
US

V. Phone/Fax

Practice location:
  • Phone: 707-725-9383
  • Fax: 707-725-1140
Mailing address:
  • Phone: 707-725-9383
  • Fax: 707-725-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2158841206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: