Provider Demographics
NPI:1649286428
Name:WHITE, WILLIAM KEITH (PA-C)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEITH
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 1:150 GENTILLY BLVD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-8522
Mailing Address - Country:US
Mailing Address - Phone:207-555-5555
Mailing Address - Fax:
Practice Address - Street 1:150 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8522
Practice Address - Country:US
Practice Address - Phone:470-490-7140
Practice Address - Fax:470-490-7139
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBGXPMedicare ID - Type UnspecifiedMEDICARE
GAP28362Medicare UPIN