Provider Demographics
NPI:1558407023
Name:AGNEW, MATTHEW JAY
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAY
Last Name:AGNEW
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 1:1749 HAMILTON RD STE 102E
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1941
Mailing Address - Country:US
Mailing Address - Phone:517-482-2118
Mailing Address - Fax:517-372-5006
Practice Address - Street 1:2900 COLLINS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8394
Practice Address - Country:US
Practice Address - Phone:517-377-8225
Practice Address - Fax:517-372-5006
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704212178367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704212178OtherSTATE LICENSE NUMBER