Provider Demographics
NPI:1275660474
Name:WHITE, PETER T (MA, ATC, EMT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:WHITE
Suffix:
Gender:M
Credentials:MA, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 GARDINER DR
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7634
Mailing Address - Country:US
Mailing Address - Phone:631-665-0426
Mailing Address - Fax:
Practice Address - Street 1:3385 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7660
Practice Address - Country:US
Practice Address - Phone:631-737-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000823-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer