Provider Demographics
NPI:1679189831
Name:WHITE, MITA
Entity Type:Individual
Prefix:
First Name:MITA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
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 1687
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1687
Mailing Address - Country:US
Mailing Address - Phone:970-254-3180
Mailing Address - Fax:970-254-3198
Practice Address - Street 1:2596 F RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1443
Practice Address - Country:US
Practice Address - Phone:970-254-3180
Practice Address - Fax:970-254-3198
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.007391363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000206956Medicaid