Provider Demographics
NPI:1942590914
Name:WHITTED, DANIEL T (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:WHITTED
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 1:6590 W NORWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8765
Mailing Address - Country:US
Mailing Address - Phone:208-855-2410
Mailing Address - Fax:208-855-0157
Practice Address - Street 1:6590 W NORWOOD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8765
Practice Address - Country:US
Practice Address - Phone:208-855-2410
Practice Address - Fax:208-855-0157
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-884363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical