Healthcare Provider Details

I. General information

NPI: 1922768860
Provider Name (Legal Business Name): KYLE WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR
LA MESA CA
91942-3020
US

IV. Provider business mailing address

6511 EASTON RD
NEW LOTHROP MI
48460-9716
US

V. Phone/Fax

Practice location:
  • Phone: 619-464-3353
  • Fax:
Mailing address:
  • Phone: 810-247-3892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61705
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: