Provider Demographics
NPI:1447528328
Name:FAGBENRO, CARLOS (NP)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:FAGBENRO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15337 LORD CULPEPER CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4937
Mailing Address - Country:US
Mailing Address - Phone:571-594-9110
Mailing Address - Fax:
Practice Address - Street 1:6360 HOADLY RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3422
Practice Address - Country:US
Practice Address - Phone:571-594-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily