=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316152846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA MARIA AGNEW MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 09/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 NE 139TH ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-487-5014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 NE 139TH ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD29245
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD60087832
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------