Provider Demographics
NPI:1164966925
Name:AGBOR, ROSE BETAK (NP)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:BETAK
Last Name:AGBOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 4TH AVE N
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1189
Mailing Address - Country:US
Mailing Address - Phone:612-543-3000
Mailing Address - Fax:
Practice Address - Street 1:1015 4TH AVE N
Practice Address - Street 2:SUITE 201
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1189
Practice Address - Country:US
Practice Address - Phone:612-543-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4731363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner