Provider Demographics
NPI:1093781379
Name:WHITE, DAWN M (PA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:M
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:M
Other - Last Name:UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:49 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1889
Practice Address - Country:US
Practice Address - Phone:315-261-5550
Practice Address - Fax:315-261-5599
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY310 269 156OtherSTATE DRIVERS LICENSE
Q10347Medicare UPIN
PA1201Medicare ID - Type Unspecified