Provider Demographics
NPI:1104509850
Name:AGAMATA, ALEXIA KATE (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:ALEXIA
Middle Name:KATE
Last Name:AGAMATA
Suffix:
Gender:F
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:27 HAWKSMOOR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1536
Mailing Address - Country:US
Mailing Address - Phone:949-351-3008
Mailing Address - Fax:
Practice Address - Street 1:2075 NEWPORT BLVD STE 107
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2179
Practice Address - Country:US
Practice Address - Phone:949-836-5239
Practice Address - Fax:949-301-9608
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA304407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist