Healthcare Provider Details

I. General information

NPI: 1477044550
Provider Name (Legal Business Name): NICODEME WANKO AGASSY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

1 RICHMOND ST APT 4012
NEW BRUNSWICK NJ
08901-4102
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 240-715-7885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA11170500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1026325
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberW5615
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: