Provider Demographics
NPI:1497797302
Name:AGNEW, ANN C (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:C
Last Name:AGNEW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 E OPUS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5274
Mailing Address - Country:US
Mailing Address - Phone:208-344-4824
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:3080 E GENTRY WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3013
Practice Address - Country:US
Practice Address - Phone:208-947-5390
Practice Address - Fax:208-947-3465
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9138208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806964100Medicaid
IDF26003Medicare UPIN
ID1100532Medicare ID - Type Unspecified