Provider Demographics
NPI:1639100266
Name:AGNEW, KRISTINE K (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:K
Last Name:AGNEW
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:K
Other - Last Name:MCCUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:304-414-4801
Practice Address - Street 1:4607 MACCORKLE AVE SW STE 206
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1364
Practice Address - Country:US
Practice Address - Phone:304-766-1133
Practice Address - Fax:304-766-1136
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV412363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical