Provider Demographics
NPI:1871541425
Name:WHITLOCK, RANDALL G JR (PA-C)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:G
Last Name:WHITLOCK
Suffix:JR
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 1:1430 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON COURT HOUSE
Mailing Address - State:OH
Mailing Address - Zip Code:43160-1703
Mailing Address - Country:US
Mailing Address - Phone:740-620-4069
Mailing Address - Fax:740-620-4072
Practice Address - Street 1:1430 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON COURT HOUSE
Practice Address - State:OH
Practice Address - Zip Code:43160
Practice Address - Country:US
Practice Address - Phone:740-620-4069
Practice Address - Fax:740-620-4072
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q23863Medicare UPIN
WHPA23461Medicare PIN