Provider Demographics
NPI:1851671119
Name:BERRY, CRISTA R (PA)
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:R
Last Name:BERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2854 BELL ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1721
Mailing Address - Country:US
Mailing Address - Phone:740-454-3273
Mailing Address - Fax:740-588-1081
Practice Address - Street 1:2854 BELL ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1721
Practice Address - Country:US
Practice Address - Phone:740-454-3273
Practice Address - Fax:740-588-1081
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003313363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309375Medicaid
OH0214380001Medicare NSC
OH0309375Medicaid