Provider Demographics
NPI:1023077641
Name:ROBERTS, ANGELA S (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:S
Last Name:ROBERTS
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 1:11 RIVERSIDE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7840
Mailing Address - Country:US
Mailing Address - Phone:321-221-7447
Mailing Address - Fax:
Practice Address - Street 1:11 RIVERSIDE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7840
Practice Address - Country:US
Practice Address - Phone:321-221-7447
Practice Address - Fax:321-221-7448
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000258A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005813400Medicaid