Provider Demographics
NPI:1285657890
Name:COLEMAN, ANGELA (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 INDIAN GRAVE RD.
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018
Mailing Address - Country:US
Mailing Address - Phone:540-725-3060
Mailing Address - Fax:540-772-4948
Practice Address - Street 1:5303 INDIAN GRAVE RD.
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-725-3060
Practice Address - Fax:540-772-4948
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA580659Medicaid
VA580659Medicaid
VAP01690336Medicare PIN