Healthcare Provider Details

I. General information

NPI: 1447434311
Provider Name (Legal Business Name): BRADLEY O WHYTE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WHITEHALL RD
ROCHESTER NH
03867
US

IV. Provider business mailing address

3998 FAIR RIDGE DR SUITE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 603-335-8159
  • Fax: 703-335-8887
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200560018CRNA
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number063874-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: