Healthcare Provider Details

I. General information

NPI: 1649133208
Provider Name (Legal Business Name): EDDIE DEAN TYLER WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4626
  • Fax: 336-716-5438
Mailing address:
  • Phone: 336-716-4626
  • Fax: 336-716-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06351
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: