Healthcare Provider Details

I. General information

NPI: 1124280391
Provider Name (Legal Business Name): NICOLE R AGOSTINELLI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-6222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number260276
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC156148
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number443518
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD443518
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: