Provider Demographics
NPI:1629397641
Name:AGNESE, DANIEL DOMINICK (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:DOMINICK
Last Name:AGNESE
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TAUGHANNOCK BLVD STE 1C
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3251
Mailing Address - Country:US
Mailing Address - Phone:607-252-3500
Mailing Address - Fax:607-252-3505
Practice Address - Street 1:310 TAUGHANNOCK BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3251
Practice Address - Country:US
Practice Address - Phone:607-252-3500
Practice Address - Fax:607-252-3505
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030031-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00332729Medicaid
NY00330317Medicare PIN