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General NPI Number Information
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NPI Number | 1750649653
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Entity Type | Individual
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Provider Name | ZACHARY JORDAN WHITAKER PA
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Gender | Male
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Dates
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Enumeration Date | 04/27/2012
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Last Update Date | 05/15/2021
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Provider Practice Location Address
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Address Line | 1 MEADOWS PKWY
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City | VIDALIA
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State | GA
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Zip | 30474-8759
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Country | US
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Telephone | 912-535-5555
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Fax |
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Provider Business Mailing Address
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Address Line | 1056 C.V. MOSLEY BLVD
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City | VIDALIA
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State | GA
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Zip | 30474
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 6460
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License Number State | GA
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