Provider Demographics
NPI:1144245523
Name:PATTERSON, ANGELA L (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3396
Mailing Address - Country:US
Mailing Address - Phone:573-727-2772
Mailing Address - Fax:
Practice Address - Street 1:130 E HARBIN AVE
Practice Address - Street 2:
Practice Address - City:PUXICO
Practice Address - State:MO
Practice Address - Zip Code:63960-9104
Practice Address - Country:US
Practice Address - Phone:573-222-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG84547Medicare UPIN