Healthcare Provider Details

I. General information

NPI: 1013900380
Provider Name (Legal Business Name): KEVIN WHITE C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 08/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SIXTH ST SW
CANTON OH
44710-1702
US

IV. Provider business mailing address

2600 SIXTH ST SW
CANTON OH
44710-1702
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-7462
  • Fax: 330-363-7679
Mailing address:
  • Phone: 330-363-7462
  • Fax: 330-363-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number162576
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: