Provider Demographics
NPI:1538239066
Name:WHITMORE, JAMES (CRNA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:WHITMORE
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 1374
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1374
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-525-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-18699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0001795Medicaid
ID0001795Medicaid