Healthcare Provider Details

I. General information

NPI: 1215586664
Provider Name (Legal Business Name): AGAVE THERAPEUTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11022 S 51ST ST STE 101
PHOENIX AZ
85044-1789
US

IV. Provider business mailing address

11022 S 51ST ST STE 101
PHOENIX AZ
85044-1789
US

V. Phone/Fax

Practice location:
  • Phone: 708-308-0852
  • Fax: 480-383-6371
Mailing address:
  • Phone: 708-308-0852
  • Fax: 480-383-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANET KAY OLSON
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 708-308-0852