1467828590 NPI number — MS. PAIGE BRIANNE WHITE PA-C

Table of content: MS. PAIGE BRIANNE WHITE PA-C (NPI 1467828590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467828590 NPI number — MS. PAIGE BRIANNE WHITE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
PAIGE
Provider Middle Name:
BRIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467828590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11945 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-396-1725
Provider Business Mailing Address Fax Number:
904-396-4893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 IRVING ST NW
Provider Second Line Business Practice Location Address:
SUITE NA1177
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20010-3017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-877-4848
Provider Business Practice Location Address Fax Number:
202-877-2468
Provider Enumeration Date:
08/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9114659 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA031148 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111421600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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