Provider Demographics
NPI:1689949356
Name:BARRY, CHARLES EDWIN
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWIN
Last Name:BARRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 W WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1564
Mailing Address - Country:US
Mailing Address - Phone:319-541-6501
Mailing Address - Fax:
Practice Address - Street 1:300 SIOUX VALLEY DR
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1205
Practice Address - Country:US
Practice Address - Phone:712-225-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA129223390200000X
IAD129223367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program