Basic Information
| Provider Information | |||||||||
| NPI: | 1982992996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITEHEAD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1148 | ||||||||
| Address2: | |||||||||
| City: | POTEAU | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749531148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186353566 | ||||||||
| FaxNumber: | 9186353309 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 WALL ST | ||||||||
| Address2: | |||||||||
| City: | POTEAU | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749534433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186353566 | ||||||||
| FaxNumber: | 9186353309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2011 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R871679 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | R113988 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 9957742 | 01 | MS | AETNA | OTHER | P01009724 | 01 | MS | RAILROAD MEDICARE | OTHER | 200499820B | 05 | OK | MEDICAID | 08277891 | 05 | MS | MEDICAID |