Provider Demographics
NPI:1093445744
Name:WHITE, KEEGAN J (PA-C)
Entity Type:Individual
Prefix:
First Name:KEEGAN
Middle Name:J
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA-C
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67 DERRICK DR
Mailing Address - Street 2:
Mailing Address - City:W HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-8914
Mailing Address - Country:US
Mailing Address - Phone:585-953-7296
Mailing Address - Fax:
Practice Address - Street 1:5141 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1159
Practice Address - Country:US
Practice Address - Phone:585-953-7296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical