Provider Demographics
NPI:1285100487
Name:AUGUSTINE, AGNES
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 INWOOD RD
Practice Address - Street 2:6TH FL, STE 6.102
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9083
Practice Address - Country:US
Practice Address - Phone:214-645-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138171363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner