Provider Demographics
NPI:1407263106
Name:AGTAY, TEODORO (APN)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:
Last Name:AGTAY
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7730 W CHEYENNE AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8412
Mailing Address - Country:US
Mailing Address - Phone:725-221-1568
Mailing Address - Fax:725-333-9218
Practice Address - Street 1:7730 W CHEYENNE AVE STE 107
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-8412
Practice Address - Country:US
Practice Address - Phone:725-221-1568
Practice Address - Fax:725-333-9218
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001770363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner