Basic Information
| Provider Information | |||||||||
| NPI: | 1922338425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N BAILEY ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743614201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251600 | ||||||||
| FaxNumber: | 9188246316 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 N BAILEY ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743614201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188251600 | ||||||||
| FaxNumber: | 9188246316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 82301 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 82301 | 01 | OK | STATE | OTHER |