Provider Demographics
NPI:1992452460
Name:BERRY, RICHARD (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:3310 E BERRENDO RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-9186
Mailing Address - Country:US
Mailing Address - Phone:575-607-8005
Mailing Address - Fax:
Practice Address - Street 1:117 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5151
Practice Address - Country:US
Practice Address - Phone:575-627-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-04
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68533367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program