Provider Demographics
NPI:1932127644
Name:BLACK, ANGELIQUE V (PA)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:V
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:11240 WAPLES MILL ROAD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-246-8080
Mailing Address - Fax:703-691-4932
Practice Address - Street 1:1850 TOWN CENTER PARKWAY
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-689-0300
Practice Address - Fax:703-787-9664
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0110002122363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
017937C95Medicare ID - Type Unspecified