Provider Demographics
NPI:1396756300
Name:BERRY, JO ANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:ANNE
Last Name:BERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:JODY
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:485 N KS HWY 2
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:KS
Mailing Address - Zip Code:67003
Mailing Address - Country:US
Mailing Address - Phone:620-914-1200
Mailing Address - Fax:
Practice Address - Street 1:1101 E SPRING ST
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:KS
Practice Address - Zip Code:67003-2122
Practice Address - Country:US
Practice Address - Phone:620-842-5144
Practice Address - Fax:620-842-3372
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501016363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200378490AMedicaid
KS426833OtherBCBS
KS426833OtherBCBS