Provider Demographics
NPI:1073363834
Name:AGNEW, ROBERT JR (EMT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:AGNEW
Suffix:JR
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-2615
Mailing Address - Country:US
Mailing Address - Phone:305-607-5623
Mailing Address - Fax:
Practice Address - Street 1:3440 N 54TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2802
Practice Address - Country:US
Practice Address - Phone:305-607-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70117917146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic