Provider Demographics
NPI:1326364894
Name:AGBONZE, PRINCE ROLAND
Entity Type:Individual
Prefix:MR
First Name:PRINCE
Middle Name:ROLAND
Last Name:AGBONZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 NE 156TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5101
Mailing Address - Country:US
Mailing Address - Phone:503-891-4266
Mailing Address - Fax:503-284-4067
Practice Address - Street 1:2817 NE 156TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5101
Practice Address - Country:US
Practice Address - Phone:503-891-4266
Practice Address - Fax:503-284-4067
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR374U00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide