Provider Demographics
NPI:1013687029
Name:AGBORUCHE, TIA DOMINIQUE
Entity Type:Individual
Prefix:MRS
First Name:TIA
Middle Name:DOMINIQUE
Last Name:AGBORUCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:DOMINIQUE
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20418 BINDER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1913
Mailing Address - Country:US
Mailing Address - Phone:313-333-4038
Mailing Address - Fax:
Practice Address - Street 1:20418 BINDER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1913
Practice Address - Country:US
Practice Address - Phone:313-333-4038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704311021163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse