Provider Demographics
NPI:1730405044
Name:ROGERS, ANGELA YOUNG (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:YOUNG
Last Name:ROGERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:MICHELLE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1970 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:540-982-2463
Mailing Address - Fax:540-855-3406
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-855-3406
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02143363A00000X
VA0110-004595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8102881Medicaid
NC8102881Medicaid