Provider Demographics
NPI:1700397627
Name:WHITE, ANGELA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:JAROSCAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13953 S BANGERTER PKWY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5429
Mailing Address - Country:US
Mailing Address - Phone:385-900-4090
Mailing Address - Fax:801-365-1033
Practice Address - Street 1:13953 S BANGERTER PKWY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5429
Practice Address - Country:US
Practice Address - Phone:385-900-4090
Practice Address - Fax:801-365-1033
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10540353-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant