Provider Demographics
NPI:1518367622
Name:AGRICOLA, DENNIS (NP)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:AGRICOLA
Suffix:
Gender:M
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:PO BOX 1050
Mailing Address - Street 2:
Mailing Address - City:CHINA
Mailing Address - State:TX
Mailing Address - Zip Code:77613-1050
Mailing Address - Country:US
Mailing Address - Phone:409-658-5395
Mailing Address - Fax:
Practice Address - Street 1:6200 KNAUTH ROAD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77705
Practice Address - Country:US
Practice Address - Phone:409-658-5395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily