Provider Demographics
NPI:1770590010
Name:WHITEHURST, ROBERT LANIER (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LANIER
Last Name:WHITEHURST
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 1:12553 HONEYCHURCH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8483
Mailing Address - Country:US
Mailing Address - Phone:919-434-9350
Mailing Address - Fax:919-453-0365
Practice Address - Street 1:#136 4441 SIX FORKS ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5729
Practice Address - Country:US
Practice Address - Phone:919-434-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC152932367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051981Medicaid
NC2606909BMedicare PIN