Provider Demographics
NPI:1043488943
Name:AGNANT, EMMANUEL (PA)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:AGNANT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 E 161ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3543
Mailing Address - Country:US
Mailing Address - Phone:718-886-9000
Mailing Address - Fax:718-961-0666
Practice Address - Street 1:4012 80TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1234
Practice Address - Country:US
Practice Address - Phone:718-886-9000
Practice Address - Fax:718-961-0666
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NYG400050952Medicare PIN