Healthcare Provider Details

I. General information

NPI: 1215260294
Provider Name (Legal Business Name): MS. MARIE PALMER WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15TH FLOOR, EAST WING 1200 EAST BROAD STREET
RICHMOND VA
23298
US

IV. Provider business mailing address

1809 PARK AVE APT 2
RICHMOND VA
23220-2820
US

V. Phone/Fax

Practice location:
  • Phone: 804-827-1207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA030628
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005678
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: