Healthcare Provider Details

I. General information

NPI: 1174974125
Provider Name (Legal Business Name): KRISTINA AGBAYANI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE PSC 117
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

3801 MIRANDA AVE PSC 117
PALO ALTO CA
94304-1207
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax:
Mailing address:
  • Phone: 650-493-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY28060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: