Provider Demographics
NPI:1841210804
Name:WHITE, WILLIAM J (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9986 GRAPEVINE HWY STE D
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3111
Mailing Address - Country:US
Mailing Address - Phone:817-918-4763
Mailing Address - Fax:817-383-1216
Practice Address - Street 1:1604 HOSPITAL PKWY
Practice Address - Street 2:SUITE 407
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6986
Practice Address - Country:US
Practice Address - Phone:817-510-5000
Practice Address - Fax:817-510-5001
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA03441363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C0775Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER