MEDICARE: JAY KENNETH AGNEW III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367H00000X	Anesthesiologist Assistant	75000240A	IN

General Provider Information

NPI Number	:	1689542144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAY KENNETH AGNEW III

Provider Business Mailing Address
First Line	:	5823 SAN CLEMENTE DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-1123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 N SENATE BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-1239
Country	:	US
Telephone Number	:	317-962-2000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2025
Last Update Date	:	01/12/2026

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