Provider Demographics
NPI:1649233735
Name:WHITE, ERIC TODD (CRNA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:TODD
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 801143
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1143
Mailing Address - Country:US
Mailing Address - Phone:573-331-3000
Mailing Address - Fax:573-331-5073
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5150
Practice Address - Fax:573-331-5026
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138089367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO918458605Medicaid
MOA002OtherCHAMPUS TRICARE
MOP00028029OtherRAILROAD MEDICARE
MO110375OtherHEALTH LINK
IL237246265401Medicaid
MO405586OtherBCBS
MO105557OtherHEALTH ALLIANCE
MO918458605Medicaid