Provider Demographics
NPI:1528210655
Name:WHITE, RICHARD E (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:WHITE
Suffix:
Gender:M
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 1:703 SEAWELL DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-3872
Mailing Address - Country:US
Mailing Address - Phone:702-672-8997
Mailing Address - Fax:
Practice Address - Street 1:DIRAIMONDO FAMILY MEDICINE CLINIC
Practice Address - Street 2:BLDG 1041
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-526-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1082491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant