Provider Demographics
NPI:1427891043
Name:AGBATOR, AKENZUA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AKENZUA
Middle Name:
Last Name:AGBATOR
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4253 46TH AVE N APT 305
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2949
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11660363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health