Provider Demographics
NPI:1144238437
Name:BERRY, JAMES (CRNA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 565
Mailing Address - Street 2:
Mailing Address - City:JOHNSON
Mailing Address - State:AR
Mailing Address - Zip Code:72741-0565
Mailing Address - Country:US
Mailing Address - Phone:479-872-1294
Mailing Address - Fax:
Practice Address - Street 1:3318 N NORTHHILLS BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4008
Practice Address - Country:US
Practice Address - Phone:479-872-1294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00887367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S706Medicare ID - Type UnspecifiedMEDICARE AND ARBCBS PROV.