Provider Demographics
NPI:1548882855
Name:AGAMATA, ROMMEL DIZON
Entity type:Individual
Prefix:
First Name:ROMMEL
Middle Name:DIZON
Last Name:AGAMATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 REDLAND DR
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-9321
Mailing Address - Country:US
Mailing Address - Phone:336-338-0341
Mailing Address - Fax:
Practice Address - Street 1:2401 S SIDE BLVD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-3311
Practice Address - Country:US
Practice Address - Phone:336-604-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP-10248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist