Basic Information
| Provider Information | |||||||||
| NPI: | 1063457612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YORK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | COOS BAY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974202099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412675151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 102436 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 201150055NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1407812365 | 01 | OR | NBMC-MAIN GROUP NPI | OTHER | 93-0635514 | 01 | OR | NBMC-MAIN GROUP TAX ID FOR BILLING | OTHER | 161133 | 01 | OR | NBMC-MAIN GROUP DMAP | OTHER | 500635199 | 05 | OR | MEDICAID | R0000WFBTV | 01 | OR | NBMC-MAIN GROUP MEDICARE | OTHER | 39234355 | 05 | CO | MEDICAID |