Healthcare Provider Details

I. General information

NPI: 1154827798
Provider Name (Legal Business Name): DEOGRACIAS REMANDABAN AGNILA JR. NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6488 103RD ST STE B
JACKSONVILLE FL
32210-7161
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 904-450-6810
  • Fax: 904-450-6729
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number9256167
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9256167
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: