Basic Information
| Provider Information | |||||||||
| NPI: | 1881883064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMOANI | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | KWAFOA MIMI | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17095 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923456004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602417575 | ||||||||
| Practice Location | |||||||||
| Address1: | 17095 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923456004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602416666 | ||||||||
| FaxNumber: | 7602417575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 12/21/2011 | ||||||||
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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 | 363A00000X | PAC1076081 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PAC1076081 | 05 | CA | MEDICAID |