Healthcare Provider Details

I. General information

NPI: 1508306473
Provider Name (Legal Business Name): RUSSELL WHITE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2017
Last Update Date: 02/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 BLUEWATER BLVD SUITE 100
NICEVILLE FL
32578-3887
US

IV. Provider business mailing address

1950 BLUEWATER BLVD SUITE 100
NICEVILLE FL
32578-3887
US

V. Phone/Fax

Practice location:
  • Phone: 850-897-8081
  • Fax: 850-897-1520
Mailing address:
  • Phone: 850-897-8081
  • Fax: 850-897-1520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9110128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: