1982394193 NPI number — JHUN DANIELE GRUESO AGONOY PTA

Table of content: JHUN DANIELE GRUESO AGONOY PTA (NPI 1982394193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982394193 NPI number — JHUN DANIELE GRUESO AGONOY PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AGONOY
Provider First Name:
JHUN DANIELE
Provider Middle Name:
GRUESO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AGONOY
Provider Other First Name:
JD
Provider Other Middle Name:
GRUESO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1982394193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 S WILLOW ST STE 128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03103-5723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-681-9294
Provider Business Mailing Address Fax Number:
888-979-6551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3838 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-357-1706
Provider Business Practice Location Address Fax Number:
503-270-5023
Provider Enumeration Date:
05/10/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  10156 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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