Provider Demographics
NPI:1043225634
Name:LATHAM, ANGELA S (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:LATHAM
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 1:2705 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4346
Mailing Address - Country:US
Mailing Address - Phone:912-264-6133
Mailing Address - Fax:912-267-1415
Practice Address - Street 1:2705 WILDWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4346
Practice Address - Country:US
Practice Address - Phone:912-264-6133
Practice Address - Fax:912-267-1415
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA084105015AMedicaid
GA97WCHKPMedicare ID - Type Unspecified
GAQ65970Medicare UPIN