Healthcare Provider Details

I. General information

NPI: 1649000316
Provider Name (Legal Business Name): MARIA ALEXIS AGUSTIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2279 45TH ST
SACRAMENTO CA
95817-1514
US

IV. Provider business mailing address

2279 45TH ST
SACRAMENTO CA
95817-1514
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-2716
  • Fax:
Mailing address:
  • Phone: 916-703-2716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0218X
TaxonomyPediatric Oncology Registered Nurse
License Number95269612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: