Provider Demographics
NPI:1518204486
Name:WHITAKER, ZACKARY JAKE (CRNA)
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:JAKE
Last Name:WHITAKER
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 1:234 ED TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:GA
Mailing Address - Zip Code:31647-4335
Mailing Address - Country:US
Mailing Address - Phone:229-392-0757
Mailing Address - Fax:
Practice Address - Street 1:47 INDIAN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029-2077
Practice Address - Country:US
Practice Address - Phone:888-728-0882
Practice Address - Fax:478-974-0110
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188133163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse