Provider Demographics
NPI:1013966969
Name:LOWERY, ANGELLE P (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELLE
Middle Name:P
Last Name:LOWERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 OCEAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3421
Mailing Address - Country:US
Mailing Address - Phone:228-875-8291
Mailing Address - Fax:877-504-3044
Practice Address - Street 1:1137 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3421
Practice Address - Country:US
Practice Address - Phone:228-875-8291
Practice Address - Fax:877-504-3044
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA069363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1936776Medicaid
MS203211285OtherTAX IDENTIFICATION NUMBER
MS1936776Medicaid
MS203211285OtherTAX IDENTIFICATION NUMBER