Provider Demographics
NPI:1396392460
Name:HASS, AGNIESZKA MALGORZATA
Entity Type:Individual
Prefix:
First Name:AGNIESZKA
Middle Name:MALGORZATA
Last Name:HASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1246
Mailing Address - Country:US
Mailing Address - Phone:732-687-7092
Mailing Address - Fax:
Practice Address - Street 1:776 E THRID AVENUE
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203
Practice Address - Country:US
Practice Address - Phone:908-241-5545
Practice Address - Fax:908-241-5548
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00950100363L00000X, 363LG0600X
NJ26ZNJ00950100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology