Basic Information
| Provider Information | |||||||||
| NPI: | 1053379917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANGELORO | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1405 WINDWARD LN | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325784343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508978978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 995 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508637887 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 05/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP3065242 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 155292 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 050542 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 053324-23-11 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000694196C | 05 | GA | MEDICAID |