Provider Demographics
NPI:1871770081
Name:WETHERILL, PAUL MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:WETHERILL
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 1:1141 DESERTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-9150
Mailing Address - Country:US
Mailing Address - Phone:760-352-4846
Mailing Address - Fax:760-352-4846
Practice Address - Street 1:1141 DESERTVIEW AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-9150
Practice Address - Country:US
Practice Address - Phone:760-352-4846
Practice Address - Fax:760-352-4846
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant