Provider Demographics
NPI:1649207705
Name:VERGARA, AGNES ADAN (PT)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:ADAN
Last Name:VERGARA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7775 MOKENA CT
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-5647
Mailing Address - Country:US
Mailing Address - Phone:727-723-5480
Mailing Address - Fax:727-849-5355
Practice Address - Street 1:7775 MOKENA CT
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-5647
Practice Address - Country:US
Practice Address - Phone:727-723-5480
Practice Address - Fax:727-849-5355
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL76052251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6142Medicare ID - Type Unspecified