Basic Information
| Provider Information | |||||||||
| NPI: | 1154998540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 LAKE CUMBERLAND RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404568431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562195 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1770 LAKE CUMBERLAND RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 404568431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062562195 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2021 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC120 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | TC120 | 01 | KY | MEDICAL LICENSE | OTHER |