Provider Demographics
NPI:1720084585
Name:GROVERMAN, ANGELA GALE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:GALE
Last Name:GROVERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:GALE
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:866-205-8079
Practice Address - Street 1:12140 NEW YORK RANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-9407
Practice Address - Country:US
Practice Address - Phone:209-257-2400
Practice Address - Fax:209-257-2403
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP72895Medicare UPIN
CA0PA150370Medicare PIN