Provider Demographics
NPI:1174022206
Name:WHITE, RUSSELL WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WILLIAM
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 POINTE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5525
Mailing Address - Country:US
Mailing Address - Phone:941-792-1404
Mailing Address - Fax:941-761-0712
Practice Address - Street 1:6015 POINTE WEST BLVD
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5525
Practice Address - Country:US
Practice Address - Phone:941-782-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1141269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0IVK6OtherFL BCBS