Provider Demographics
NPI:1841206620
Name:WHITE, ALFRED J (CRNA)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:J
Last Name:WHITE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:A
Other - Middle Name:JAMES
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 78600
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8600
Mailing Address - Country:US
Mailing Address - Phone:414-777-1623
Mailing Address - Fax:414-777-1628
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-334-5533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42051-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43279800Medicaid
R40393Medicare UPIN
WI0004 21215Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID #