Provider Demographics
NPI:1336539436
Name:WHITE, NATHAN BOYD (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:BOYD
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 1:6475 S YALE AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7815
Mailing Address - Country:US
Mailing Address - Phone:918-494-9341
Mailing Address - Fax:918-494-9355
Practice Address - Street 1:6475 S YALE AVE STE 301
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-494-9300
Practice Address - Fax:918-494-9355
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2422363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200572790AMedicaid