Healthcare Provider Details

I. General information

NPI: 1619916434
Provider Name (Legal Business Name): SAMUEL WHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 MATTHEW DR
WAYNESBORO MS
39367-2567
US

IV. Provider business mailing address

950 MATTHEW DR
WAYNESBORO MS
39367-2590
US

V. Phone/Fax

Practice location:
  • Phone: 601-735-7101
  • Fax: 601-735-7181
Mailing address:
  • Phone: 601-735-7101
  • Fax: 601-735-7181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR860585
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: