Provider Demographics
NPI:1194961623
Name:BERRY, TRAVIS LEON (CRNA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEON
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 1:110 29TH AVE N
Mailing Address - Street 2:STE 202
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1401
Mailing Address - Country:US
Mailing Address - Phone:615-327-4304
Mailing Address - Fax:
Practice Address - Street 1:110 29TH AVE N
Practice Address - Street 2:STE 202
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1401
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN80402367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200345160AMedicaid
OK200345160AMedicaid