Provider Demographics
NPI:1629152293
Name:WHITE, KIRSTIN NALL (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:NALL
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 1:3355 RIVERBEND DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8800
Mailing Address - Country:US
Mailing Address - Phone:541-686-8353
Mailing Address - Fax:541-681-3078
Practice Address - Street 1:3355 RIVERBEND DR
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-686-8353
Practice Address - Fax:541-681-3078
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL850002050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant