Provider Demographics
NPI:1750505780
Name:SCOTT WHITAKER CRNA PC
Entity Type:Organization
Organization Name:SCOTT WHITAKER CRNA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:801-643-3506
Mailing Address - Street 1:268 W 4050 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1182
Mailing Address - Country:US
Mailing Address - Phone:801-643-3506
Mailing Address - Fax:
Practice Address - Street 1:268 W 4050 N
Practice Address - Street 2:
Practice Address - City:PLEASANT VIEW
Practice Address - State:UT
Practice Address - Zip Code:84414-1182
Practice Address - Country:US
Practice Address - Phone:801-643-3506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN30696367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806452700Medicaid
ID1378391Medicare ID - Type Unspecified