Healthcare Provider Details

I. General information

NPI: 1265443048
Provider Name (Legal Business Name): MICHAEL R BERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

PO BOX 517 605 MILLER LANE
SAINT CLAIR MN
56080-0517
US

V. Phone/Fax

Practice location:
  • Phone: 507-345-2623
  • Fax: 507-389-4685
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR139685-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: