Provider Demographics
NPI:1922005917
Name:DEPERGOLA, ANGELA (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DEPERGOLA
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 1:499 FARMINGTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1933
Mailing Address - Country:US
Mailing Address - Phone:860-221-8594
Mailing Address - Fax:
Practice Address - Street 1:499 FARMINGTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1933
Practice Address - Country:US
Practice Address - Phone:860-549-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000869363AS0400X, 363A00000X
MAPA1056363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003008695Medicaid