Provider Demographics
NPI:1518723477
Name:AGBO, SOMTOCHUKWU QUEEN
Entity Type:Individual
Prefix:
First Name:SOMTOCHUKWU
Middle Name:QUEEN
Last Name:AGBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOMTOCHUKWU
Other - Middle Name:NMESOMA
Other - Last Name:UME UGWA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23232 WILLOW GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-5693
Mailing Address - Country:US
Mailing Address - Phone:813-352-7398
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024416363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care