MEDICARE: AGNES PETERS RN

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	163W00000X	Registered Nurse	433721	NY

General Provider Information

NPI Number	:	1790149623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGNES PETERS RN

Provider Business Mailing Address
First Line	:	10 CRYSTAL COMMONS DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-2274
Country	:	US
Telephone Number	:	607-739-4277
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 CRYSTAL COMMONS DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14624-2274
Country	:	US
Telephone Number	:	607-739-4277
Fax Number	:

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

Provider Enumeration Date	:	04/06/2016
Last Update Date	:	04/06/2016

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