Provider Demographics
NPI:1740287119
Name:NORTHCUTT, ANGELA M (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:NORTHCUTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-5296
Mailing Address - Country:US
Mailing Address - Phone:812-778-3116
Mailing Address - Fax:812-778-3117
Practice Address - Street 1:123 S FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-5296
Practice Address - Country:US
Practice Address - Phone:812-778-3116
Practice Address - Fax:812-778-3117
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9948363AS0400X
WV1612-023363AS0400X
TXPA04880363AS0400X
IN10003396A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9563OtherBLUE CROSS BLUE SHIELD OF
WI42865500Medicaid
MN559168600Medicaid
WI42865500Medicaid
TX8J3618Medicare PIN