Provider Demographics
NPI:1205872777
Name:DIUBLE, ANGELA L (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:DIUBLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 SEAGATE STE 800
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:517-423-4777
Mailing Address - Fax:517-423-7257
Practice Address - Street 1:6869 S OCCIDENTAL RD
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-9784
Practice Address - Country:US
Practice Address - Phone:517-423-4777
Practice Address - Fax:517-423-7257
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI003500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205872777Medicaid
MIP00710650Medicare PIN
MIMI1174002Medicare PIN
MIN82810028Medicare PIN