Provider Demographics
NPI:1386842201
Name:WHITE, HEIDI K (PA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:K
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1102
Mailing Address - Country:US
Mailing Address - Phone:909-599-9921
Mailing Address - Fax:909-592-3147
Practice Address - Street 1:150 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1102
Practice Address - Country:US
Practice Address - Phone:909-599-9921
Practice Address - Fax:909-592-3147
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant