Healthcare Provider Details

I. General information

NPI: 1386089357
Provider Name (Legal Business Name): KATIE MARIE WHITE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE ELLIS

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 08/25/2023
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 NW 63RD ST
OKLAHOMA CITY OK
73116-4902
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 405-254-5565
  • Fax: 405-254-5569
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2217
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: