Provider Demographics
NPI:1508306473
Name:WHITE, RUSSELL (PA)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 BLUEWATER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3887
Mailing Address - Country:US
Mailing Address - Phone:850-897-8081
Mailing Address - Fax:850-897-1520
Practice Address - Street 1:1950 BLUEWATER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3887
Practice Address - Country:US
Practice Address - Phone:850-897-8081
Practice Address - Fax:850-897-1520
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9110128363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical