Healthcare Provider Details

I. General information

NPI: 1376242545
Provider Name (Legal Business Name): SAMUEL KEEGAN WHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 PROVIDENCE DR STE 207
ANCHORAGE AK
99508-4620
US

IV. Provider business mailing address

928 10TH ST
CHARLESTON IL
61920-2859
US

V. Phone/Fax

Practice location:
  • Phone: 907-279-0555
  • Fax:
Mailing address:
  • Phone: 217-264-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number255686
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: