Basic Information
| Provider Information | |||||||||
| NPI: | 1316906829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITMIRE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177263030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 FRUIT ST # 444 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177263030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 57 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN2271470 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN0497 | 05 | SC | MEDICAID |