Provider Demographics
NPI:1780673707
Name:WHITE, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-463-3044
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-463-3234
Practice Address - Fax:208-463-3044
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID970014195OtherRAILROAD MEDICARE
IDPA332OtherBLUE CROSS
ID000010017665OtherBLUECROSS
ID000010017666OtherBLUECROSS
ID805659700Medicaid
IDPA837OtherBLUE CROSS
ID970014195OtherRAILROAD MEDICARE
ID000010017665OtherBLUECROSS