Provider Demographics
NPI:1235433772
Name:GARY, AGUSTA DIANE
Entity Type:Individual
Prefix:MS
First Name:AGUSTA
Middle Name:DIANE
Last Name:GARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6128 KAMI ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6688
Mailing Address - Country:US
Mailing Address - Phone:702-632-3446
Mailing Address - Fax:
Practice Address - Street 1:6128 KAMI ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-6688
Practice Address - Country:US
Practice Address - Phone:702-632-3446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-25
Last Update Date:2010-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner