Provider Demographics
NPI:1275160566
Name:AGHA, JERISE ATOCK (NP)
Entity Type:Individual
Prefix:
First Name:JERISE
Middle Name:ATOCK
Last Name:AGHA
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 1:111 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-7855
Mailing Address - Country:US
Mailing Address - Phone:302-373-6887
Mailing Address - Fax:
Practice Address - Street 1:7307 FOSSIL LAKE DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-4713
Practice Address - Country:US
Practice Address - Phone:302-373-6887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX845356363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care