Healthcare Provider Details

I. General information

NPI: 1992452460
Provider Name (Legal Business Name): RICHARD BERRY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E 19TH ST
ROSWELL NM
88201-5151
US

IV. Provider business mailing address

3310 E BERRENDO RD
ROSWELL NM
88201-9186
US

V. Phone/Fax

Practice location:
  • Phone: 575-627-7000
  • Fax:
Mailing address:
  • Phone: 575-607-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number68533
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: