Provider Demographics
NPI:1730811332
Name:WHITE, CRESTYN SLADE (PA-C)
Entity type:Individual
Prefix:
First Name:CRESTYN
Middle Name:SLADE
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 1:20 HALL VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9606
Mailing Address - Country:US
Mailing Address - Phone:304-413-3597
Mailing Address - Fax:
Practice Address - Street 1:806 WASENA AVE SW APT 326
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-5358
Practice Address - Country:US
Practice Address - Phone:304-413-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant