Provider Demographics
NPI:1235873449
Name:BACON, ANGELA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:BACON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3205 GRAND AVE APT 408
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-6145
Mailing Address - Country:US
Mailing Address - Phone:412-908-3972
Mailing Address - Fax:
Practice Address - Street 1:12351 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8344
Practice Address - Country:US
Practice Address - Phone:412-359-6581
Practice Address - Fax:412-359-3483
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL139305367500000X
PARN593231367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered