Healthcare Provider Details

I. General information

NPI: 1558407023
Provider Name (Legal Business Name): MR. MATTHEW JAY AGNEW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 COLLINS RD
LANSING MI
48910-8394
US

IV. Provider business mailing address

1749 HAMILTON RD STE 102E
OKEMOS MI
48864-1941
US

V. Phone/Fax

Practice location:
  • Phone: 517-377-8225
  • Fax: 517-372-5006
Mailing address:
  • Phone: 517-482-2118
  • Fax: 517-372-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704212178
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: