Healthcare Provider Details

I. General information

NPI: 1053853937
Provider Name (Legal Business Name): DAVID WHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST
BRIDGEPORT CT
06606-4292
US

IV. Provider business mailing address

99 EAST RIVER DRIVE 5TH FLOOR
EAST HARTFORD CT
06108-7301
US

V. Phone/Fax

Practice location:
  • Phone: 203-576-5877
  • Fax:
Mailing address:
  • Phone: 860-282-0833
  • Fax: 860-282-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6826
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: