Healthcare Provider Details

I. General information

NPI: 1134197221
Provider Name (Legal Business Name): ANNE ENCARNACION AGRAVIADOR CONSTANTINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 N PECOS RD
NORTH LAS VEGAS NV
89086-4400
US

IV. Provider business mailing address

10401 HOSPITAL DR SUITE 102
CLINTON MD
20735-3110
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-4540
  • Fax: 301-856-3470
Mailing address:
  • Phone: 301-877-4540
  • Fax: 301-856-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD043238
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD0074007
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number38548
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: