Provider Demographics
NPI:1124838263
Name:STANFORD, ANGELINA (PA)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:STANFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:
Other - Last Name:RAUSCHENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1914
Mailing Address - Country:US
Mailing Address - Phone:757-446-5600
Mailing Address - Fax:
Practice Address - Street 1:5021 CRAIG RATH BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-6243
Practice Address - Country:US
Practice Address - Phone:804-592-5437
Practice Address - Fax:804-592-2406
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110011067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty