Provider Demographics
NPI:1164676896
Name:DANIELSON, ANGELA B (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:B
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:WIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:144 NORTH CT
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1224
Mailing Address - Country:US
Mailing Address - Phone:815-285-5437
Mailing Address - Fax:815-285-8928
Practice Address - Street 1:144 NORTH CT
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5437
Practice Address - Fax:815-285-8928
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400262366OtherMEDICARE
ILF400262366OtherMEDICARE