Provider Demographics
NPI:1689487043
Name:AGWU, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:AGWU
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:PO BOX 67537
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-8009
Mailing Address - Country:US
Mailing Address - Phone:302-400-9999
Mailing Address - Fax:302-600-3578
Practice Address - Street 1:124 SLEEPY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5838
Practice Address - Country:US
Practice Address - Phone:302-400-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-29
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0054564163WE0003X
DELG-0013112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency