Provider Demographics
NPI:1508355538
Name:DONANGELO, MAURISSA (PA-C, PHD)
Entity Type:Individual
Prefix:
First Name:MAURISSA
Middle Name:
Last Name:DONANGELO
Suffix:
Gender:F
Credentials:PA-C, PHD
Other - Prefix:
Other - First Name:MAURISSA
Other - Middle Name:
Other - Last Name:RADAKOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C, PHD
Mailing Address - Street 1:1969 9TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6707
Mailing Address - Country:US
Mailing Address - Phone:801-712-1621
Mailing Address - Fax:
Practice Address - Street 1:526 SHOUP AVE W STE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-736-3362
Practice Address - Fax:208-736-3382
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IDPA-1970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant