Provider Demographics
NPI:1467796227
Name:ANGELO, ALEXANDRA J (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:J
Last Name:ANGELO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ALICE PECK DAY DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2900
Mailing Address - Country:US
Mailing Address - Phone:603-442-5630
Mailing Address - Fax:603-442-5631
Practice Address - Street 1:17 ALICE PECK DAY DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-2904
Practice Address - Country:US
Practice Address - Phone:603-442-5630
Practice Address - Fax:603-442-5631
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHT400292032Medicare UPIN