Healthcare Provider Details

I. General information

NPI: 1376686725
Provider Name (Legal Business Name): SCOTT D WHITAKER CRNA,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 W 4050 N
OGDEN UT
84414-1182
US

IV. Provider business mailing address

268 W 4050 N
OGDEN UT
84414-1182
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-1610
  • Fax:
Mailing address:
  • Phone: 801-782-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2142214406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: