Provider Demographics
NPI:1083719181
Name:WHITE, ANNA MARIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ANNA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:TANA
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:PO BOX 9627
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-422-9697
Mailing Address - Fax:
Practice Address - Street 1:1100 NORTH COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:479-587-5889
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-240363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR710685433OtherTAX ID
ARPA-240OtherSTATE LICENSE