Basic Information
| Provider Information | |||||||||
| NPI: | 1124276787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERRY | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325045935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504777042 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325045935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504777042 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9272095 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000373200 | 05 | FL | MEDICAID | 592-03533 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | G4623 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |