Provider Demographics
NPI:1093768699
Name:VETTERICK, ANGELA (PA C)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:VETTERICK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:ENOS
Other - Last Name:ENOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST STE 6210
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:541-383-1883
Practice Address - Street 1:500 NE A ST STE 100
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1842
Practice Address - Country:US
Practice Address - Phone:541-383-3005
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
130629Medicare ID - Type Unspecified
Q37222Medicare UPIN