Healthcare Provider Details

I. General information

NPI: 1205870649
Provider Name (Legal Business Name): LARRY KEITH WHITAKER JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEITH WHITAKER PA-C

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E ORANGE ST HOOPESTON COMMUNITY MEMORIAL HOSPITAL DBA CHARLOTTE ANN
HOOPESTON IL
60942-1802
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-283-5644
  • Fax: 217-283-7432
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002299
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085002299
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: