Provider Demographics
NPI:1063478055
Name:WHITE, JOSHUA JOHN (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:JOHN
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-738-4780
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:1818 N MEADE ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3454
Practice Address - Country:US
Practice Address - Phone:920-731-8900
Practice Address - Fax:920-225-1479
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3618174400000X
WI2096363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI450030728OtherMEDICARE PTAN
WI711290124OtherMEDICARE PTAN
WIWI2257002OtherMEDICARE PTAN
WI41937200Medicaid
GA100002112AMedicaid
WI41937200Medicaid