Basic Information
Provider Information | |||||||||
NPI: | 1245636208 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COMER | ||||||||
FirstName: | ANGELIN | ||||||||
MiddleName: | BARKER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BARKER | ||||||||
OtherFirstName: | ANGELIN | ||||||||
OtherMiddleName: | JORDAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 101 AUBREYS LOOP | ||||||||
Address2: |   | ||||||||
City: | SOUTH BOSTON | ||||||||
State: | VA | ||||||||
PostalCode: | 245925054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345173879 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 AUBREYS LOOP | ||||||||
Address2: |   | ||||||||
City: | SOUTH BOSTON | ||||||||
State: | VA | ||||||||
PostalCode: | 245925054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345173879 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2014 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/07/2020 | ||||||||
NPIReactivationDate: | 02/06/2020 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024174922 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.