Provider Demographics
NPI:1659044204
Name:AGBOLA, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:AGBOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21444 CARMEAN WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-4572
Mailing Address - Country:US
Mailing Address - Phone:302-855-1233
Mailing Address - Fax:302-855-2025
Practice Address - Street 1:LA RED HEALTH CENTER
Practice Address - Street 2:21444 CARMEAN WAY
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947
Practice Address - Country:US
Practice Address - Phone:302-855-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023612363LP0808X
DEL8-0010238363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health