Healthcare Provider Details

I. General information

NPI: 1902671712
Provider Name (Legal Business Name): MICHAELA A WHITE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 PINE ST STE 2A
PHILADELPHIA PA
19107-6187
US

IV. Provider business mailing address

23 S WOODRIDGE DR
WARRINGTON PA
18976-1027
US

V. Phone/Fax

Practice location:
  • Phone: 844-337-6362
  • Fax: 267-519-0597
Mailing address:
  • Phone: 215-431-7699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA065255
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: