Provider Demographics
NPI:1427087378
Name:WITTMAN, CHERON L (PA-C)
Entity type:Individual
Prefix:
First Name:CHERON
Middle Name:L
Last Name:WITTMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHERON
Other - Middle Name:L
Other - Last Name:MOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10004 204TH AVE E
Mailing Address - Street 2:STE 2200
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6539
Mailing Address - Country:US
Mailing Address - Phone:253-447-3300
Mailing Address - Fax:
Practice Address - Street 1:10004 204TH AVE E
Practice Address - Street 2:STE 2200
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-6539
Practice Address - Country:US
Practice Address - Phone:253-447-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS93703Medicare UPIN