Provider Demographics
NPI:1619916434
Name:WHITE, SAMUEL (CRNA)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:WHITE
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 1:950 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2590
Mailing Address - Country:US
Mailing Address - Phone:601-735-7101
Mailing Address - Fax:601-735-7181
Practice Address - Street 1:950 MATTHEW DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2567
Practice Address - Country:US
Practice Address - Phone:601-735-7101
Practice Address - Fax:601-735-7181
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860585367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02672767Medicaid
MS430002079Medicare Oscar/Certification