Healthcare Provider Details

I. General information

NPI: 1093123457
Provider Name (Legal Business Name): OLIVIA ANNE O'BERRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PINELLAS ST SUITE 400
CLEARWATER FL
33756-3354
US

IV. Provider business mailing address

455 PINELLAS ST SUITE 400
CLEARWATER FL
33756-3354
US

V. Phone/Fax

Practice location:
  • Phone: 727-445-1911
  • Fax: 727-445-1986
Mailing address:
  • Phone: 727-445-1911
  • Fax: 727-445-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9107983
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: