MEDICARE: ANGELA DEPERGOLA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	000869	CT
2	363A00000X	Physician Assistant	000869	CT
3	363AS0400X	Surgical Physician Assistant	PA1056	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922005917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA DEPERGOLA PA-C

Provider Business Mailing Address
First Line	:	499 FARMINGTON AVE STE 300
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1933
Country	:	US
Telephone Number	:	860-221-8594
Fax Number	:

Provider Business Practice Location Address
First Line	:	499 FARMINGTON AVE STE 300
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1933
Country	:	US
Telephone Number	:	860-549-3210
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	10/24/2024

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Directions to “ ANGELA DEPERGOLA PA-C” Practice Location

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