Provider Demographics
NPI:1700162740
Name:CHERNYSHOV, ANGELA (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CHERNYSHOV
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:870 111TH AVE N STE 4
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1869
Mailing Address - Country:US
Mailing Address - Phone:239-514-4200
Mailing Address - Fax:239-514-3373
Practice Address - Street 1:870 111TH AVE N STE 4
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1869
Practice Address - Country:US
Practice Address - Phone:239-514-4200
Practice Address - Fax:239-514-3373
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106219363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical