Healthcare Provider Details

I. General information

NPI: 1710094941
Provider Name (Legal Business Name): ETHAN A BERRY MSN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10203 NE 102ND ST
VANCOUVER WA
98662
US

V. Phone/Fax

Practice location:
  • Phone: 909-967-1734
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200560041CRNA
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200560041CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: