Healthcare Provider Details

I. General information

NPI: 1447528328
Provider Name (Legal Business Name): CARLOS FAGBENRO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 HOADLY RD
MANASSAS VA
20112-3422
US

IV. Provider business mailing address

15337 LORD CULPEPER CT
WOODBRIDGE VA
22191-4937
US

V. Phone/Fax

Practice location:
  • Phone: 571-594-9110
  • Fax:
Mailing address:
  • Phone: 571-594-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024169586
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: