Provider Demographics
NPI:1033886213
Name:WHITE, CONNOR JAKOB
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:JAKOB
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-1518
Mailing Address - Country:US
Mailing Address - Phone:304-550-2924
Mailing Address - Fax:
Practice Address - Street 1:11 GATEWATER RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1408
Practice Address - Country:US
Practice Address - Phone:304-206-2296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker