Provider Demographics
NPI:1417958554
Name:WHITE, BEVERLY DENE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:DENE
Last Name:WHITE
Suffix:
Gender:F
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:PO BOX 508
Mailing Address - Street 2:600 MAIN STREET
Mailing Address - City:OLTON
Mailing Address - State:TX
Mailing Address - Zip Code:79064-0508
Mailing Address - Country:US
Mailing Address - Phone:806-292-2754
Mailing Address - Fax:806-285-2175
Practice Address - Street 1:600 MAIN ST.
Practice Address - Street 2:
Practice Address - City:OLTON
Practice Address - State:TX
Practice Address - Zip Code:79064-0508
Practice Address - Country:US
Practice Address - Phone:806-285-2209
Practice Address - Fax:806-285-2209
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1032277OtherNCCPA
TXPA00190OtherPHYSICIAN ASSISTANT LICEN
TX8N4306OtherBCBS
TX8N4306OtherBCBS
TXPA00190OtherPHYSICIAN ASSISTANT LICEN