Basic Information
| Provider Information | |||||||||
| NPI: | 1164824546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | PA-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 546 | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970300132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417828242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 535 NE 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | ESTACADA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970239312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036308550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2014 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA173943 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500698127 | 05 | OR | MEDICAID |