Provider Demographics
NPI:1508013418
Name:WRIGHT, ANGELA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1753 FULTON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1927
Practice Address - Country:US
Practice Address - Phone:574-293-9448
Practice Address - Fax:574-293-9480
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99032985A363A00000X
IN10001017A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000586619OtherANTHEM PROVIDER NUMBER
IN236040442OtherMEDICARE
IN300013545Medicaid
IN815500Q4Medicare PIN