Provider Demographics
NPI:1639134562
Name:CLEMSON, ANGELIQUE (DO)
Entity Type:Individual
Prefix:DR
First Name:ANGELIQUE
Middle Name:
Last Name:CLEMSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-2537
Mailing Address - Country:US
Mailing Address - Phone:717-248-2619
Mailing Address - Fax:
Practice Address - Street 1:2023 CATO AVE STE 101
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-2765
Practice Address - Country:US
Practice Address - Phone:814-409-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010739L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001905047-0002Medicaid
PACL-1388250OtherBLUE SHEILD NETWORK
PA001388250OtherKEYSTONE HEALTH PLAN WEST
PA001905047Medicaid
PA058932D5PMedicare ID - Type Unspecified
058932Medicare PIN
PA001388250OtherKEYSTONE HEALTH PLAN WEST