Healthcare Provider Details

I. General information

NPI: 1265832844
Provider Name (Legal Business Name): ZAGBAYOU DAGBO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1604 BENTON AVE
BENTON ME
04901-3327
US

IV. Provider business mailing address

PO BOX 5062
AUGUSTA ME
04332-5062
US

V. Phone/Fax

Practice location:
  • Phone: 207-314-7440
  • Fax:
Mailing address:
  • Phone: 207-314-7440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 054555
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: