Healthcare Provider Details

I. General information

NPI: 1265088942
Provider Name (Legal Business Name): MATTHEW AGEN PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2019
Last Update Date: 08/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 S OVERLAND RD
HOBART WI
54155-8959
US

IV. Provider business mailing address

N7137 COUNTY ROAD C
SEYMOUR WI
54165-8430
US

V. Phone/Fax

Practice location:
  • Phone: 920-869-2797
  • Fax:
Mailing address:
  • Phone: 262-290-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13462-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: