Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 5648 | AZ |
NPI | 1629067806 |
---|---|
Provider Name | Trevor Sean Berry |
First Address | Tempe, AZ 85284-4558 |
Second Address | Tempe, AZ 85284-4558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
28071104 | WORKERS COMP. (01) | AZ |
641432 | UNITED HEALTH CARE (01) | AZ |
AZ 0243810 | BCBS OF AZ (01) | AZ |
U64224 | (02) | AZ |