Healthcare Provider Details

I. General information

NPI: 1164405114
Provider Name (Legal Business Name): KERRY WHITAKER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W. KALEY STREET
ORLANDO FL
32806-2931
US

IV. Provider business mailing address

20 W. KALEY STREET
ORLANDO FL
32806-2931
US

V. Phone/Fax

Practice location:
  • Phone: 407-423-2581
  • Fax: 407-849-6470
Mailing address:
  • Phone: 407-423-2581
  • Fax: 407-849-6470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 484
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAX00002031
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: