Provider Demographics
NPI:1487000519
Name:EVERIDGE, ANGEL (PA)
Entity Type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:EVERIDGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E. 65TH STREET
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-819-7878
Mailing Address - Fax:912-819-3555
Practice Address - Street 1:11700 MERCY BLVD
Practice Address - Street 2:PLAZA D, #6
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419
Practice Address - Country:US
Practice Address - Phone:912-927-3434
Practice Address - Fax:912-921-0982
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-07
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7957363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003176730BMedicaid