1447434311 NPI number — BRADLEY O WHYTE CRNA

Table of content: BRADLEY O WHYTE CRNA (NPI 1447434311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447434311 NPI number — BRADLEY O WHYTE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHYTE
Provider First Name:
BRADLEY
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447434311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 FAIR RIDGE DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-295-9360
Provider Business Mailing Address Fax Number:
703-766-9725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 WHITEHALL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-335-8159
Provider Business Practice Location Address Fax Number:
703-335-8887
Provider Enumeration Date:
12/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  200560018CRNA , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 063874-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3074691 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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