MEDICARE: MRS. LAURA RAE WHITE PA

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	PA05285	TX

General Provider Information

NPI Number	:	1700047511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA RAE WHITE PA

Provider Business Mailing Address
First Line	:	800 8TH AVE STE 326
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2602
Country	:	US
Telephone Number	:	817-885-8222
Fax Number	:	817-885-8663

Provider Business Practice Location Address
First Line	:	800 8TH AVE STE 326
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2602
Country	:	US
Telephone Number	:	817-885-8222
Fax Number	:	817-885-8663

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

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	10/26/2022

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