Provider Demographics
NPI:1629189238
Name:WHITE, JANET S (PA C)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:S
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 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1668
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:618-833-6267
Practice Address - Street 1:211 N BROADWAY
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-2323
Practice Address - Country:US
Practice Address - Phone:618-995-1002
Practice Address - Fax:618-995-1133
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211448OtherMEDICARE GROUP NUMBER
ILQ74804Medicare UPIN
ILK34526Medicare PIN