Provider Demographics
NPI:1285210815
Name:ANGELO, DAVID SHANE (NP)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:SHANE
Last Name:ANGELO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8307
Mailing Address - Country:US
Mailing Address - Phone:903-606-6400
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-606-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032557363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1N8103OtherMEDICARE
TX421635001Medicaid