MEDICARE: MRS. COURTNEY DALLAS WHITE PA C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	103974	NC

General Provider Information

NPI Number	:	1396715033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. COURTNEY DALLAS WHITE PA C

Provider Business Mailing Address
First Line	:	13251 FALLS OF NEUSE RD STE 121
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-8573
Country	:	US
Telephone Number	:	919-785-5055
Fax Number	:

Provider Business Practice Location Address
First Line	:	13251 FALLS OF NEUSE RD STE 121
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-8573
Country	:	US
Telephone Number	:	919-785-5055
Fax Number	:	919-573-6689

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	02/12/2021

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