Provider Demographics
NPI:1396337598
Name:BERRY, GUNNAR
Entity type:Individual
Prefix:
First Name:GUNNAR
Middle Name:
Last Name:BERRY
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:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26181-0026
Mailing Address - Country:US
Mailing Address - Phone:304-481-9494
Mailing Address - Fax:
Practice Address - Street 1:82 DIXIE LN
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-7212
Practice Address - Country:US
Practice Address - Phone:304-210-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker