Healthcare Provider Details

I. General information

NPI: 1821277542
Provider Name (Legal Business Name): IAN WHITMARSH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

PO BOX 7389 ATTN: REBECCA EASON CPPA
LONGVIEW TX
75607-7389
US

V. Phone/Fax

Practice location:
  • Phone: 918-579-5207
  • Fax:
Mailing address:
  • Phone: 888-260-6614
  • Fax: 903-257-0815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30007888
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: