Healthcare Provider Details

I. General information

NPI: 1922005917
Provider Name (Legal Business Name): ANGELA DEPERGOLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/24/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 FARMINGTON AVE STE 300
FARMINGTON CT
06032-1933
US

IV. Provider business mailing address

499 FARMINGTON AVE STE 300
FARMINGTON CT
06032-1933
US

V. Phone/Fax

Practice location:
  • Phone: 860-549-3210
  • Fax:
Mailing address:
  • Phone: 860-221-8594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000869
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000869
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: