Provider Demographics
NPI:1215586664
Name:AGAVE THERAPEUTICS PLLC
Entity Type:Organization
Organization Name:AGAVE THERAPEUTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:708-308-0852
Mailing Address - Street 1:11022 S 51ST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-1789
Mailing Address - Country:US
Mailing Address - Phone:708-308-0852
Mailing Address - Fax:480-383-6371
Practice Address - Street 1:11022 S 51ST ST STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-1789
Practice Address - Country:US
Practice Address - Phone:708-308-0852
Practice Address - Fax:480-383-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service