Healthcare Provider Details

I. General information

NPI: 1639100266
Provider Name (Legal Business Name): KRISTINE K AGNEW P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINE K. MCCUE

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 MACCORKLE AVE SW STE 206
SOUTH CHARLESTON WV
25309-1364
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 304-766-1133
  • Fax: 304-766-1136
Mailing address:
  • Phone: 304-414-4800
  • Fax: 304-414-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number412
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number412
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: