Provider Demographics
NPI:1225369861
Name:CLEMENTS, ANGELA J (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:CLEMENTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:J
Other - Last Name:WILLITS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID STREET
Mailing Address - Street 2:C/O CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1990 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9315
Practice Address - Country:US
Practice Address - Phone:360-856-4222
Practice Address - Fax:360-854-2705
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60130940363A00000X
WAOA60199442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1225369861Medicaid
WA273214OtherLABOR & INDUSTRIES
WA273214OtherLABOR & INDUSTRIES