Provider Demographics
NPI:1770657702
Name:KOGUT, ANGELA MARIE (PAC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:KOGUT
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 1:3801 SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-2311
Mailing Address - Country:US
Mailing Address - Phone:928-757-2101
Mailing Address - Fax:
Practice Address - Street 1:3535 S SMITH RD STE A
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-9270
Practice Address - Country:US
Practice Address - Phone:330-208-2720
Practice Address - Fax:330-208-2721
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2259532Medicaid
OH2259532Medicaid