Provider Demographics
NPI:1487921409
Name:HOLT, ANGELINA DAWN (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELINA
Middle Name:DAWN
Last Name:HOLT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:DAWN
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1824 KING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-384-3343
Mailing Address - Fax:904-400-6671
Practice Address - Street 1:1824 KING ST STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4736
Practice Address - Country:US
Practice Address - Phone:904-384-3343
Practice Address - Fax:904-400-6671
Is Sole Proprietor?:No
Enumeration Date:2011-11-18
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006317363A00000X
VA0110005126363A00000X
TXPA12050363A00000X
CT4254363A00000X
FLPA9116010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00994128OtherRAILROAD MEDICARE
GA003118596AMedicaid
01477593OtherAMERIGROUP
SC1319PAMedicaid
GA643345OtherWELLCARE
GA202I977520Medicare PIN