Provider Demographics
NPI:1134149883
Name:WHITFIELD, RAYMOND LYLE (CRNA)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:LYLE
Last Name:WHITFIELD
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 1:1150 MOORES GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-1516
Mailing Address - Country:US
Mailing Address - Phone:706-742-8496
Mailing Address - Fax:706-742-5383
Practice Address - Street 1:1150 MOORES GROVE RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30683-1516
Practice Address - Country:US
Practice Address - Phone:706-742-8496
Practice Address - Fax:706-742-5383
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN070093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000623224BMedicaid
GA43ZCBRG30Medicare ID - Type UnspecifiedCRNA
GA000623224BMedicaid