Provider Demographics
NPI:1174859250
Name:MITTMAN, ANGELA SUZANNE (PA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:SUZANNE
Last Name:MITTMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3427
Mailing Address - Country:US
Mailing Address - Phone:484-620-2485
Mailing Address - Fax:
Practice Address - Street 1:5800 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1737
Practice Address - Country:US
Practice Address - Phone:215-487-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMAO54173363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical