Provider Demographics
NPI:1376520205
Name:WHITE, MICHAEL CHAD (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHAD
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1635 E MYRTLE AVE
Mailing Address - Street 2:STE 400
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-5514
Mailing Address - Country:US
Mailing Address - Phone:602-944-2900
Mailing Address - Fax:602-944-0064
Practice Address - Street 1:1635 E MYRTLE AVE
Practice Address - Street 2:STE 400
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5514
Practice Address - Country:US
Practice Address - Phone:602-944-2900
Practice Address - Fax:602-944-0064
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2171363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ112981Medicare PIN
S91822Medicare UPIN
AZ706202Medicaid