Healthcare Provider Details

I. General information

NPI: 1700848512
Provider Name (Legal Business Name): MICHAEL E WHOBERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 E WALNUT ST
WASHINGTON IN
47501-2120
US

IV. Provider business mailing address

PO BOX 32
WASHINGTON IN
47501-0032
US

V. Phone/Fax

Practice location:
  • Phone: 812-254-2760
  • Fax: 812-254-8636
Mailing address:
  • Phone: 812-254-2760
  • Fax: 812-254-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28066860A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: