Provider Demographics
NPI:1588295810
Name:HEATH, ANGELA MICHELE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MICHELE
Last Name:HEATH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 E H AVE
Mailing Address - Street 2:
Mailing Address - City:MILBURN
Mailing Address - State:OK
Mailing Address - Zip Code:73450-9445
Mailing Address - Country:US
Mailing Address - Phone:580-443-3564
Mailing Address - Fax:580-443-3503
Practice Address - Street 1:108 E H AVE
Practice Address - Street 2:
Practice Address - City:MILBURN
Practice Address - State:OK
Practice Address - Zip Code:73450-9445
Practice Address - Country:US
Practice Address - Phone:580-443-3564
Practice Address - Fax:580-443-3503
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA3179363A00000X
CA65215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200897140AMedicaid