MEDICARE: MARIE L WHITE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	005122	GA

General Provider Information

NPI Number	:	1710138680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE L WHITE PA-C

Provider Business Mailing Address
First Line	:	1502 W 3RD ST
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1979
Country	:	US
Telephone Number	:	678-774-0430
Fax Number	:	770-775-3410

Provider Business Practice Location Address
First Line	:	1502 W 3RD ST
Second Line	:
City	:	JACKSON
State	:	GA
Zip	:	30233-1979
Country	:	US
Telephone Number	:	678-774-0430
Fax Number	:	770-775-3410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/09/2008
Last Update Date	:	02/03/2009

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Directions to “ MARIE L WHITE PA-C” Practice Location

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