Provider Demographics
NPI:1487729828
Name:ANGELA INGENDAAY, M.D., PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:ANGELA INGENDAAY, M.D., PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:I
Authorized Official - Last Name:INGENDAAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-272-0537
Mailing Address - Street 1:150 S AUBURN STREET
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-272-0537
Mailing Address - Fax:530-692-2053
Practice Address - Street 1:150 S AUBURN STREET
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-272-0537
Practice Address - Fax:530-692-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
CAA52909261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00949Medicare UPIN