Provider Demographics
NPI:1063722577
Name:WATHEN, ILI (PA-C)
Entity type:Individual
Prefix:
First Name:ILI
Middle Name:
Last Name:WATHEN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11565 FARM DR
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5417
Mailing Address - Country:US
Mailing Address - Phone:301-752-3667
Mailing Address - Fax:240-222-3134
Practice Address - Street 1:85 HIGH ST STE 3
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2150
Practice Address - Country:US
Practice Address - Phone:301-396-2003
Practice Address - Fax:240-222-3134
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant