Healthcare Provider Details

I. General information

NPI: 1962950188
Provider Name (Legal Business Name): ANTHONY T WHALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 CHORRO ST STE A2
SAN LUIS OBISPO CA
93405-2396
US

IV. Provider business mailing address

1515 5TH ST
LOS OSOS CA
93402-1611
US

V. Phone/Fax

Practice location:
  • Phone: 805-321-5080
  • Fax: 877-752-3742
Mailing address:
  • Phone: 805-321-5080
  • Fax: 877-752-3742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: