Provider Demographics
NPI:1093123457
Name:O'BERRY, OLIVIA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ANNE
Last Name:O'BERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 PINELLAS ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3354
Mailing Address - Country:US
Mailing Address - Phone:727-445-1911
Mailing Address - Fax:727-445-1986
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:SUITE 400
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3354
Practice Address - Country:US
Practice Address - Phone:727-445-1911
Practice Address - Fax:727-445-1986
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9107983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHY244ZMedicare PIN