Provider Demographics
NPI:1457879330
Name:WITCHER, ALEX MICHAEL (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:MICHAEL
Last Name:WITCHER
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918
Mailing Address - Country:US
Mailing Address - Phone:256-339-2637
Mailing Address - Fax:
Practice Address - Street 1:307 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918
Practice Address - Country:US
Practice Address - Phone:256-339-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.453211163W00000X
IL114630207L00000X
MO2023043288367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
114630OtherNBCRNA