Provider Demographics
NPI:1245006147
Name:DEANGELIS, DOMINIQUE RAE (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:RAE
Last Name:DEANGELIS
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 1:3 ANASVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-2415
Mailing Address - Country:US
Mailing Address - Phone:845-661-0100
Mailing Address - Fax:
Practice Address - Street 1:5 PERRYRIDGE RD
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4697
Practice Address - Country:US
Practice Address - Phone:203-863-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031018363AM0700X
CT6374363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical