Provider Demographics
NPI:1053385054
Name:WHITTENBERG, PHILLIP BRIAN (PA C)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRIAN
Last Name:WHITTENBERG
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-820-3581
Mailing Address - Fax:702-796-2335
Practice Address - Street 1:2716 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-877-5199
Practice Address - Fax:702-242-7842
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-845363AM0700X
NVPA751363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P68813Medicare UPIN