Healthcare Provider Details

I. General information

NPI: 1063478055
Provider Name (Legal Business Name): JOSHUA JOHN WHITE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-8900
  • Fax: 920-225-1479
Mailing address:
  • Phone: 920-738-4780
  • Fax: 920-738-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3618
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2096
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: