Provider Demographics
NPI:1013052703
Name:WHITE, JOAN (PA)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
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 1:100 GRANNY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-2879
Mailing Address - Country:US
Mailing Address - Phone:631-696-4357
Mailing Address - Fax:631-846-8138
Practice Address - Street 1:100 GRANNY RD STE 1
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2879
Practice Address - Country:US
Practice Address - Phone:631-696-4357
Practice Address - Fax:631-846-8138
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006205-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant