Provider Demographics
NPI:1669845285
Name:AGUDELO, CARLOS A (PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:AGUDELO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NW 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2835
Mailing Address - Country:US
Mailing Address - Phone:954-608-2220
Mailing Address - Fax:
Practice Address - Street 1:4111 STIRLING RD
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7535
Practice Address - Country:US
Practice Address - Phone:954-608-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant