Provider Demographics
NPI:1295124618
Name:SHERIDAN, ANGELINA (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:
Other - Last Name:SHERIDAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:396 BRYAN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-6268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 GRADY RD STE B
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1911
Practice Address - Country:US
Practice Address - Phone:423-263-0722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2699OtherTN LICENSE
TN1295124618OtherNPI
TN1511366Medicaid
TN13510582OtherCAQH
TN4207616OtherBCBS PROVIDER ID
TN4207616OtherBCBS PROVIDER ID