Healthcare Provider Details

I. General information

NPI: 1346862075
Provider Name (Legal Business Name): ZACHARY J WHIPPLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W EATON AVE
TRACY CA
95376-3420
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-4062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: