Provider Demographics
NPI:1679541767
Name:ANGELITIS, DAVID ANDREW (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:ANGELITIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21724
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1724
Mailing Address - Country:US
Mailing Address - Phone:215-208-0824
Mailing Address - Fax:
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:877-872-5788
Practice Address - Fax:866-698-7272
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00162000363A00000X
PAMA051059363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ124273XURMedicare PIN
PA086970Medicare ID - Type Unspecified