Basic Information
| Provider Information | |||||||||
| NPI: | 1508513532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 STATE HIGHWAY 248 STE 2E | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656164078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175531197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2022 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1194283 | 01 | NCCPA | OTHER |