Provider Demographics
NPI:1174815021
Name:BERRY, GRANT WILSON (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:WILSON
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
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 1810
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-1810
Mailing Address - Country:US
Mailing Address - Phone:307-206-4172
Mailing Address - Fax:
Practice Address - Street 1:2100 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2274
Practice Address - Country:US
Practice Address - Phone:307-857-3445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD043197207P00000X
TXR5511207P00000X
WY10598A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine