=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821277542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN WHITMARSH CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2007
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 S UTICA AVE
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74104-4012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-579-5207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7389 ATTN: REBECCA EASON CPPA
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75607-7389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-260-6614
-----------------------------------------------------
Fax | 903-257-0815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | AP30007888
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------