Provider Demographics
NPI:1982992996
Name:WHITEHEAD, DAVID R (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:WHITEHEAD
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 1148
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-1148
Mailing Address - Country:US
Mailing Address - Phone:918-635-3566
Mailing Address - Fax:918-635-3309
Practice Address - Street 1:105 WALL ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4433
Practice Address - Country:US
Practice Address - Phone:918-635-3566
Practice Address - Fax:918-635-3309
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871679367500000X
OKR113988367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9957742OtherAETNA
MSP01009724OtherRAILROAD MEDICARE
OK200499820BMedicaid
MS08277891Medicaid
MS08277891Medicaid