Provider Demographics
NPI:1003063827
Name:AGEN, JANICE M (NP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:AGEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:M
Other - Last Name:GIACOPPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-5210
Mailing Address - Fax:315-464-2141
Practice Address - Street 1:90 PRESIDENTIAL PLZ
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2240
Practice Address - Country:US
Practice Address - Phone:315-464-5210
Practice Address - Fax:315-464-2141
Is Sole Proprietor?:No
Enumeration Date:2008-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421076363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03500736Medicaid
NY03500736Medicaid