Healthcare Provider Details

I. General information

NPI: 1982085858
Provider Name (Legal Business Name): TAD WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2015
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALLACE WAY
GRANDVIEW WA
98930
US

IV. Provider business mailing address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

V. Phone/Fax

Practice location:
  • Phone: 509-788-1702
  • Fax:
Mailing address:
  • Phone: 509-882-3444
  • Fax: 509-882-4097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60861324
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: