Provider Demographics
NPI:1467462945
Name:CEREZO, ANGELA JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:CEREZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:JEAN
Other - Last Name:PASCUAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-397-6344
Mailing Address - Fax:757-606-1185
Practice Address - Street 1:600 CRAWFORD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3820
Practice Address - Country:US
Practice Address - Phone:757-397-6344
Practice Address - Fax:757-606-1185
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001759363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467462945Medicaid
VAPAROtherUSA MANAGED CARE
VAPAROtherCORVEL
VA-003OtherTRICARE/CHAMPUS
VAPAROtherMULTIPLAN
VA10093799POtherOPTIMA HEALTH
NVQ13003Medicare UPIN
VA1467462945Medicaid