Provider Demographics
NPI:1730529371
Name:WHITE, JONATHAN ANDREW (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ANDREW
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 W PITTSBURG ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9011
Mailing Address - Country:US
Mailing Address - Phone:918-629-2407
Mailing Address - Fax:
Practice Address - Street 1:1015 W WASHBOURNE ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346-4205
Practice Address - Country:US
Practice Address - Phone:918-253-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA2267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant