Provider Demographics
NPI:1790912103
Name:ANAK-AGUNG-GEDE, ANGELA ISKANDAR (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ISKANDAR
Last Name:ANAK-AGUNG-GEDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:GRACIA
Other - Last Name:ISKANDAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:480 4TH AVENUE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-426-3240
Mailing Address - Fax:619-426-5964
Practice Address - Street 1:480 4TH AVENUE
Practice Address - Street 2:SUITE 307
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-426-3240
Practice Address - Fax:619-426-5964
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19998363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19998OtherSTATE LICENSE