Provider Demographics
NPI:1629434980
Name:MIEDEMA, ANGELA RACHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RACHELLE
Last Name:MIEDEMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 896208
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6208
Mailing Address - Country:US
Mailing Address - Phone:910-715-1010
Mailing Address - Fax:
Practice Address - Street 1:150 IVEY LN STE A
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9817
Practice Address - Country:US
Practice Address - Phone:910-215-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-01
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001954A363A00000X
NC0010-09633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant