Healthcare Provider Details

I. General information

NPI: 1992490551
Provider Name (Legal Business Name): TREVOR BARRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5486 BUCKEYE ST RM 123
DAYTON OH
45433-5411
US

IV. Provider business mailing address

559 VINCENT ST., SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914-5411
US

V. Phone/Fax

Practice location:
  • Phone: 702-576-6625
  • Fax:
Mailing address:
  • Phone: 702-576-6625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: