Provider Demographics
NPI:1548775950
Name:MIHNGHA, AGNES EWO
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:EWO
Last Name:MIHNGHA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AGNES
Other - Middle Name:EWO
Other - Last Name:MIHNGHA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:KEDZE
Mailing Address - Street 1:3139 SUDBURY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-4316
Mailing Address - Country:US
Mailing Address - Phone:704-890-7799
Mailing Address - Fax:704-394-3395
Practice Address - Street 1:407 W KING ST
Practice Address - Street 2:
Practice Address - City:KINGS MTN
Practice Address - State:NC
Practice Address - Zip Code:28086
Practice Address - Country:US
Practice Address - Phone:704-730-8461
Practice Address - Fax:704-730-8349
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC211009OtherNCBON
MD2017028672OtherANCC
NC5010069OtherNCBON