Provider Demographics
NPI:1114249299
Name:AGWAGOM, EMMANUEL (RN)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:
Last Name:AGWAGOM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 GREY WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4633
Mailing Address - Country:US
Mailing Address - Phone:817-719-3775
Mailing Address - Fax:817-704-4046
Practice Address - Street 1:1515 GREY WILLOW LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-4633
Practice Address - Country:US
Practice Address - Phone:817-719-3775
Practice Address - Fax:817-704-4046
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX742099163W00000X, 171M00000X
NJ26NR11805800163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health