Provider Demographics
NPI:1497058259
Name:WHITE, GLENN RAY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:RAY
Last Name:WHITE
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:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011002332367500000X
IAD130493367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360434Medicare UPIN