Provider Demographics
NPI:1093962045
Name:AGRESTA, DOMINIC EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:EDWARD
Last Name:AGRESTA
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 JAKE ALEXANDER BLVD W
Practice Address - Street 2:STE 105
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1364
Practice Address - Country:US
Practice Address - Phone:704-403-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01450363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093962045Medicaid
NC29651OtherLICENSE NUMBER
NC8102398Medicaid
NC8102398Medicaid
NCNCG393DMedicare PIN
NCNCG393FMedicare PIN
NC1093962045Medicaid
NC2762446Medicare PIN
NCNCG393BMedicare PIN
NCNCG393CMedicare PIN