Provider Demographics
NPI:1548069131
Name:AGAHAN, PAOLO MIGUEL DELA CRUZ (PTA)
Entity type:Individual
Prefix:
First Name:PAOLO MIGUEL
Middle Name:DELA CRUZ
Last Name:AGAHAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 PACIFICA DR APT 307
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1150
Mailing Address - Country:US
Mailing Address - Phone:863-206-8299
Mailing Address - Fax:
Practice Address - Street 1:1180 PACIFICA DR APT 307
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1150
Practice Address - Country:US
Practice Address - Phone:863-206-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26763208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty