Provider Demographics
NPI:1417329640
Name:COVARRUBIAS, AGATHA J (NP)
Entity Type:Individual
Prefix:
First Name:AGATHA
Middle Name:J
Last Name:COVARRUBIAS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AGATHA
Other - Middle Name:I
Other - Last Name:JOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 M ST
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-2121
Mailing Address - Country:US
Mailing Address - Phone:205-586-1983
Mailing Address - Fax:209-874-3896
Practice Address - Street 1:3105 MCHENRY AVE STE 101
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1439
Practice Address - Country:US
Practice Address - Phone:209-575-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70897207R00000X
CA95069913207Q00000X
CAA76562207R00000X
WA60579117364SA2200X
CA95002944363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093183261Medicaid
CA1093183261Medicare Oscar/Certification
CA1093183261Medicaid
CA1093183261Medicare NSC
CA1093183261Medicare PIN