Provider Demographics
NPI:1598088635
Name:KELLERMEYER, ANGELA (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KELLERMEYER
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:PO BOX 2268
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-2268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 3RD ST NW STE 102
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-6137
Practice Address - Country:US
Practice Address - Phone:828-855-1192
Practice Address - Fax:828-358-0832
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790246AMedicaid
NC2762226Medicare PIN