Provider Demographics
NPI:1942720891
Name:ANGELINO, ERICA LYNNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:LYNNE
Last Name:ANGELINO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:LYNNE
Other - Last Name:STOCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4976 ALPHA LN
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-5470
Mailing Address - Country:US
Mailing Address - Phone:423-497-5355
Mailing Address - Fax:423-308-0281
Practice Address - Street 1:929 SPRING CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412-3974
Practice Address - Country:US
Practice Address - Phone:423-629-9743
Practice Address - Fax:423-629-9744
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4634363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103358470Medicaid
NY04791851Medicaid