Provider Demographics
NPI:1861721391
Name:PETERSON, ANGELA KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:KELLY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:KELLY
Other - Last Name:STEELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8740 RIVERS AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-572-5990
Mailing Address - Fax:843-552-4121
Practice Address - Street 1:8740 RIVERS AVENUE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-572-5990
Practice Address - Fax:843-552-4121
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC642363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1805PAMedicaid