Provider Demographics
NPI:1124437330
Name:HALL, WHITNEY J (PA-C)
Entity type:Individual
Prefix:MISS
First Name:WHITNEY
Middle Name:J
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:WHITNEY
Other - Middle Name:J
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:LICKING
Mailing Address - State:MO
Mailing Address - Zip Code:65542-0047
Mailing Address - Country:US
Mailing Address - Phone:573-674-3011
Mailing Address - Fax:573-674-4765
Practice Address - Street 1:233 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LICKING
Practice Address - State:MO
Practice Address - Zip Code:65542-0047
Practice Address - Country:US
Practice Address - Phone:573-674-3011
Practice Address - Fax:573-674-4765
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027661363A00000X
MO2014031392363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124437330Medicaid
MO26D0679044OtherCLIA
MO268630Medicare Oscar/Certification
MO26D0679044OtherCLIA