Provider Demographics
NPI:1861911570
Name:WHITBORD, MATTHEW TYLER (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TYLER
Last Name:WHITBORD
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 1:2921 DE LA VINA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-3309
Mailing Address - Country:US
Mailing Address - Phone:805-770-3999
Mailing Address - Fax:
Practice Address - Street 1:2921 DE LA VINA ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-3309
Practice Address - Country:US
Practice Address - Phone:805-770-3999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1841216082207NS0135X
CA54839363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty