Provider Demographics
NPI:1104919240
Name:WHITE, KATRINA A (PA)
Entity type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:KATRINA
Other - Middle Name:A
Other - Last Name:TRIMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-0690
Mailing Address - Country:US
Mailing Address - Phone:308-872-2486
Mailing Address - Fax:308-872-2027
Practice Address - Street 1:145 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-0690
Practice Address - Country:US
Practice Address - Phone:308-872-2486
Practice Address - Fax:308-872-2027
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1174207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEQ30793Medicare UPIN