Provider Demographics
NPI:1225685589
Name:AGNESE, GINO PASQUALE
Entity Type:Individual
Prefix:
First Name:GINO
Middle Name:PASQUALE
Last Name:AGNESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUTE 9 N STE 410
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1003
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:31 NEW DORP LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2351
Practice Address - Country:US
Practice Address - Phone:718-979-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist