Provider Demographics
NPI:1265443048
Name:BERRY, MICHAEL R (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 517
Mailing Address - Street 2:605 MILLER LANE
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MN
Mailing Address - Zip Code:56080-0517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-345-2623
Practice Address - Fax:507-389-4685
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR139685-2367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN637498000Medicaid
967551047349OtherPREFERRED ONE
2003612OtherMEDICA
436L0BEOtherBCBS OF MN
133973OtherUCARE
HP68767OtherHEALTH PARTNERS