Provider Demographics
NPI:1942274642
Name:WHITE, CONNIE R (PA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HAYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67060-1471
Mailing Address - Country:US
Mailing Address - Phone:316-469-1099
Mailing Address - Fax:316-469-1098
Practice Address - Street 1:7030 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HAYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:67060-1471
Practice Address - Country:US
Practice Address - Phone:316-469-1099
Practice Address - Fax:316-469-1098
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1600384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200360660AMedicaid
Q61428Medicare UPIN
KS200360660AMedicaid