Provider Demographics
NPI:1285625822
Name:BERRY, RONALD ARTHUR (RN, FNP)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:ARTHUR
Last Name:BERRY
Suffix:
Gender:M
Credentials:RN, FNP
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 1209
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97761-1209
Mailing Address - Country:US
Mailing Address - Phone:541-553-1196
Mailing Address - Fax:541-553-2457
Practice Address - Street 1:1270 KOTNUM ROAD
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:OR
Practice Address - Zip Code:97761-1209
Practice Address - Country:US
Practice Address - Phone:541-553-1196
Practice Address - Fax:541-553-2457
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17377.148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273855Medicaid
ORHSZ204OtherMEDICARE FEDERAL HEALTH CARE FACILITY
NM8HD971OtherPERSONAL MEDICARE ID
NM8HD971OtherPERSONAL MEDICARE ID