Provider Demographics
NPI:1982940920
Name:VERVOORT, ANGELA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:VERVOORT
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 1:805 JOHNSON ST SW
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:IA
Mailing Address - Zip Code:52033-8636
Mailing Address - Country:US
Mailing Address - Phone:563-852-7756
Mailing Address - Fax:563-852-7759
Practice Address - Street 1:805 JOHNSON ST SW
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:IA
Practice Address - Zip Code:52033-8636
Practice Address - Country:US
Practice Address - Phone:563-852-7756
Practice Address - Fax:563-852-7759
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002350363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical