Provider Demographics
NPI:1912992124
Name:WHITAKER, DANIEL LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:WHITAKER
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 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-2240
Mailing Address - Fax:812-450-2710
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-1674
Practice Address - Country:US
Practice Address - Phone:812-450-2240
Practice Address - Fax:812-450-2710
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28069763A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100383050Medicaid
IN000000249974OtherSIA ANTHEM
IN090540046Medicare PIN
R29233Medicare UPIN
IN000000249974OtherSIA ANTHEM
IN000000249974OtherSIA ANTHEM