Healthcare Provider Details

I. General information

NPI: 1689949356
Provider Name (Legal Business Name): MR. CHARLES EDWIN BARRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SIOUX VALLEY DR
CHEROKEE IA
51012-1205
US

IV. Provider business mailing address

1125 W WILLOW ST
CHEROKEE IA
51012-1564
US

V. Phone/Fax

Practice location:
  • Phone: 712-225-5101
  • Fax:
Mailing address:
  • Phone: 319-541-6501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD129223
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number129223
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: