Provider Demographics
NPI:1548326028
Name:WITTY, ROBERT RAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RAY
Last Name:WITTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:25634 SAN THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-5845
Mailing Address - Country:US
Mailing Address - Phone:951-924-8121
Mailing Address - Fax:951-243-7787
Practice Address - Street 1:12810 HEACOCK ST
Practice Address - Street 2:SUITE B-206
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2854
Practice Address - Country:US
Practice Address - Phone:951-485-5155
Practice Address - Fax:951-485-5152
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA 12064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ 05231Medicare UPIN