Provider Demographics
NPI:1588635635
Name:WHITACRE, WILLIAM C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:C
Last Name:WHITACRE
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:CMR 402 BOX 1852
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-0019
Mailing Address - Country:US
Mailing Address - Phone:01149172-825-3813
Mailing Address - Fax:
Practice Address - Street 1:6400 SE LAKE RD STE 130
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97222-2129
Practice Address - Country:US
Practice Address - Phone:503-594-1774
Practice Address - Fax:503-594-1775
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201260035CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered