Healthcare Provider Details

I. General information

NPI: 1922338425
Provider Name (Legal Business Name): DAVID MATTHEW WHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N BAILEY ST
PRYOR OK
74361-4201
US

IV. Provider business mailing address

111 N BAILEY ST
PRYOR OK
74361-4201
US

V. Phone/Fax

Practice location:
  • Phone: 918-825-1600
  • Fax: 918-824-6316
Mailing address:
  • Phone: 918-825-1600
  • Fax: 918-824-6316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number82301
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: