Healthcare Provider Details

I. General information

NPI: 1336116664
Provider Name (Legal Business Name): WALTER A. WITHERSPOON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

716 WRIGHT LN
MARSHALL MI
49068-9612
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 772-269-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9198797
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: