Provider Demographics
NPI:1003371923
Name:WHICKER, CULLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:CULLEN
Middle Name:
Last Name:WHICKER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 COREY LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1130
Mailing Address - Country:US
Mailing Address - Phone:217-972-4546
Mailing Address - Fax:
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4192
Practice Address - Country:US
Practice Address - Phone:217-876-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018652367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered