Provider Demographics
NPI:1992831895
Name:ANGELO, JOSEPH MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:ANGELO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5134
Mailing Address - Country:US
Mailing Address - Phone:318-212-3610
Mailing Address - Fax:318-212-3709
Practice Address - Street 1:7925 YOUREE DR STE 200
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5134
Practice Address - Country:US
Practice Address - Phone:318-212-3610
Practice Address - Fax:318-212-3709
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10405363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B103P1660Medicare ID - Type Unspecified
LA5B103P660Medicare PIN
LA5B103Medicare PIN
LAP16167Medicare UPIN