Provider Demographics
NPI:1427425172
Name:AGONCILLO, STEPHANIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:AGONCILLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 CHANTICLEER AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1815
Mailing Address - Country:US
Mailing Address - Phone:831-477-2350
Mailing Address - Fax:
Practice Address - Street 1:2911 CHANTICLEER AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1815
Practice Address - Country:US
Practice Address - Phone:831-477-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
CA53464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant