Healthcare Provider Details

I. General information

NPI: 1326013012
Provider Name (Legal Business Name): GREGORY ALAN WHITE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 INDUSTRIAL PARK RD
NIANTIC CT
06357-1210
US

IV. Provider business mailing address

82 NEW PARK AVE
NORTH FRANKLIN CT
06254-1807
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-7345
  • Fax:
Mailing address:
  • Phone: 860-889-7345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: