Provider Demographics
NPI:1376396135
Name:AGANS, DYLAN EDWIN (MPH, RD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:EDWIN
Last Name:AGANS
Suffix:
Gender:M
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 VALENTINA WAY APT 306
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303
Mailing Address - Country:US
Mailing Address - Phone:714-882-0185
Mailing Address - Fax:
Practice Address - Street 1:2298 LONGSTREET RD A FORT LIBERTY
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:714-882-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86153149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered