MEDICARE: NICOLLE E 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	002437	CT
2	363AM0700X	Medical Physician Assistant	002437	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002437	OTHER	CT	LICENSE

General Provider Information

NPI Number	:	1841500675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLLE E WHITE PA-C

Provider Business Mailing Address
First Line	:	1918 BLACK ROCK TPKE
Second Line	:
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3543
Country	:	US
Telephone Number	:	203-583-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1918 BLACK ROCK TPKE
Second Line	:
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3543
Country	:	US
Telephone Number	:	203-583-8400
Fax Number	:

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

Provider Enumeration Date	:	10/14/2010
Last Update Date	:	12/02/2016

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Directions to “ NICOLLE E WHITE PA-C” Practice Location

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