Basic Information
| Provider Information | |||||||||
| NPI: | 1538102488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARKER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LESTOURGEON | ||||||||
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| Credential: | MS, PT | ||||||||
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| OtherLastName: | LESTOURGEON | ||||||||
| OtherFirstName: | ANGELA | ||||||||
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| OtherCredential: | MS, PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045605595 | ||||||||
| FaxNumber: | 8045609029 | ||||||||
| Practice Location | |||||||||
| Address1: | 7650 E PARHAM RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232944373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042826338 | ||||||||
| FaxNumber: | 8042853237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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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 | 225100000X | 2305203317 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00761610 | 01 | VA | RR MEDICARE | OTHER | 008953104 | 05 | VA | MEDICAID |