Provider Demographics
NPI:1154827798
Name:AGNILA, DEOGRACIAS REMANDABAN JR (NP-C)
Entity Type:Individual
Prefix:MR
First Name:DEOGRACIAS
Middle Name:REMANDABAN
Last Name:AGNILA
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6488 103RD ST STE B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7161
Practice Address - Country:US
Practice Address - Phone:904-450-6810
Practice Address - Fax:904-450-6729
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9256167163WG0000X
FLAPRN9256167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice