Provider Demographics
NPI:1447434311
Name:WHYTE, BRADLEY O (CRNA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:O
Last Name:WHYTE
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 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:11 WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867
Practice Address - Country:US
Practice Address - Phone:603-335-8159
Practice Address - Fax:703-335-8887
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200560018CRNA367500000X
NH063874-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074691Medicaid