Provider Demographics
NPI:1841847563
Name:DEANGELO, DOMINIC JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JOHN
Last Name:DEANGELO
Suffix:
Gender:M
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 1:910 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-3731
Mailing Address - Country:US
Mailing Address - Phone:330-360-3874
Mailing Address - Fax:
Practice Address - Street 1:250 DEBARTOLO PL
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-7004
Practice Address - Country:US
Practice Address - Phone:300-314-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant