Provider Demographics
NPI:1508210287
Name:MAYBERRY, CARL (MBA,CRA,ARRT(R)(CT))
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:M
Credentials:MBA,CRA,ARRT(R)(CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CTR
Mailing Address - Street 2:9040 JACKSON AVE ATTN:MCHJ-CLQ-C
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:253-968-2147
Mailing Address - Fax:253-968-2024
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040 JACKSON AVE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:253-968-2147
Practice Address - Fax:253-968-2024
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
203671247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist