Healthcare Provider Details

I. General information

NPI: 1467434134
Provider Name (Legal Business Name): ROBERT NICHOLAS AGNELLO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 TT LANIER STREET
BUIES CREEK NC
27506
US

IV. Provider business mailing address

108 SPRING POND LN
SPRING LAKE NC
28390-9328
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-1560
  • Fax: 910-814-5727
Mailing address:
  • Phone: 910-813-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2011-00474
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011-00474
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: