Provider Demographics
NPI:1629518154
Name:AGU, PETRA
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:AGU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 CHESTNUT AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-6611
Mailing Address - Country:US
Mailing Address - Phone:562-443-2255
Mailing Address - Fax:
Practice Address - Street 1:1959 CHESTNUT AVE APT 305
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-6611
Practice Address - Country:US
Practice Address - Phone:562-443-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA6807770172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver