Provider Demographics
NPI:1063457612
Name:YORK, ANGELA RENEE (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:RENEE
Last Name:YORK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2099
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO102436363L00000X
OR201150055NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC-MAIN GROUP NPI
OR93-0635514OtherNBMC-MAIN GROUP TAX ID FOR BILLING
OR161133OtherNBMC-MAIN GROUP DMAP
OR500635199Medicaid
ORR0000WFBTVOtherNBMC-MAIN GROUP MEDICARE
CO39234355Medicaid
OR1407812365OtherNBMC-MAIN GROUP NPI