Provider Demographics
NPI:1033757554
Name:BARRY, ANNABETH PRUETT (PA-C, MBA)
Entity Type:Individual
Prefix:
First Name:ANNABETH
Middle Name:PRUETT
Last Name:BARRY
Suffix:
Gender:F
Credentials:PA-C, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:424 E STROOP RD UNIT B
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-2845
Practice Address - Country:US
Practice Address - Phone:937-562-2300
Practice Address - Fax:937-562-2302
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4262363A00000X
390200000X
OH50.007429RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program