=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609231877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN BERRY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2015
-----------------------------------------------------
Last Update Date | 10/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 E 28TH ST
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55407-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-342-8900
-----------------------------------------------------
Fax | 865-691-0843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8942 KNOLLWOOD DR
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55347-1722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 1864
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------