Healthcare Provider Details

I. General information

NPI: 1730529371
Provider Name (Legal Business Name): JONATHAN ANDREW WHITE P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 W WASHBOURNE ST
JAY OK
74346-4205
US

IV. Provider business mailing address

3202 W PITTSBURG ST
BROKEN ARROW OK
74012-9011
US

V. Phone/Fax

Practice location:
  • Phone: 918-253-1700
  • Fax:
Mailing address:
  • Phone: 918-629-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2267
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: