Basic Information
| Provider Information | |||||||||
| NPI: | 1093770141 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARCANGELIS | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3691 RUTGER ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149774440 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3635 VISTA AT GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631100250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145778776 | ||||||||
| FaxNumber: | 3142685697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 117364 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00657539 | 01 | MO | RR MEDICARE | OTHER |