Provider Demographics
NPI:1033150867
Name:WHITE, CLINTON M (PA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:M
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 769609
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8224
Mailing Address - Country:US
Mailing Address - Phone:770-449-0990
Mailing Address - Fax:770-448-8818
Practice Address - Street 1:6920 JIMMY CARTER BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1277
Practice Address - Country:US
Practice Address - Phone:770-449-0990
Practice Address - Fax:770-448-8818
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2768Medicare ID - Type UnspecifiedGROUP I.D.-GA CLINIC
GA97BBFFVMedicare ID - Type Unspecified
GAS77737Medicare UPIN