Provider Demographics
NPI:1386007631
Name:AGBONAVBARE, EDWIN JAPHETH (CNP)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:JAPHETH
Last Name:AGBONAVBARE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CORPORATE PL STE 303
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-3809
Mailing Address - Country:US
Mailing Address - Phone:781-640-1791
Mailing Address - Fax:
Practice Address - Street 1:100 CORPORATE PL STE 303
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-3809
Practice Address - Country:US
Practice Address - Phone:781-640-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2277840363LP0808X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty