Provider Demographics
NPI:1982225579
Name:WHITE, BEAU RANDOLPH
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:RANDOLPH
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 HOLLY HILL DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-6057
Mailing Address - Country:US
Mailing Address - Phone:252-230-5547
Mailing Address - Fax:
Practice Address - Street 1:130 MASON FARM RD
Practice Address - Street 2:3159C BIOINFORMATICS BUILDING
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:25799
Practice Address - Country:US
Practice Address - Phone:919-966-9071
Practice Address - Fax:919-966-7956
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261467390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program