Provider Demographics
NPI:1336686492
Name:ANGE, JETTA (PA-C)
Entity Type:Individual
Prefix:
First Name:JETTA
Middle Name:
Last Name:ANGE
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:4920 SW LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8339
Mailing Address - Country:US
Mailing Address - Phone:580-536-8844
Mailing Address - Fax:580-536-8818
Practice Address - Street 1:619 N MAIN ST
Practice Address - Street 2:BUILDING D
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4431
Practice Address - Country:US
Practice Address - Phone:918-682-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant