Provider Demographics
NPI:1629066659
Name:VEDIZ, ANGELA HEATHER (PAC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:HEATHER
Last Name:VEDIZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 S JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2525
Mailing Address - Country:US
Mailing Address - Phone:417-624-0440
Mailing Address - Fax:417-624-9652
Practice Address - Street 1:2829 S JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-2525
Practice Address - Country:US
Practice Address - Phone:417-624-0440
Practice Address - Fax:417-624-9652
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003002304363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000097010Medicare PIN
P86171Medicare UPIN
P86171Medicare UPIN