Provider Demographics
NPI:1972880250
Name:WHITE, JASON W (CRNA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:W
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:PO BOX 1318
Mailing Address - Street 2:
Mailing Address - City:THATCHER
Mailing Address - State:AZ
Mailing Address - Zip Code:85552-1318
Mailing Address - Country:US
Mailing Address - Phone:928-965-0707
Mailing Address - Fax:
Practice Address - Street 1:1600 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4011
Practice Address - Country:US
Practice Address - Phone:928-965-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-15
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0856367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered