Provider Demographics
NPI:1669498481
Name:AGENA, VALERIE A (DO)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:A
Last Name:AGENA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:A
Other - Last Name:HANSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:VALERIE ANN EWING
Mailing Address - Street 1:855 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2553
Mailing Address - Country:US
Mailing Address - Phone:817-735-2709
Mailing Address - Fax:
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-735-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2526207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182440010Medicaid
TX182440105Medicaid
TXM2526OtherTEXAS MEDICAL BOARD
TX182440102Medicaid
TXTXB122298Medicare PIN
TX8G7146Medicare ID - Type Unspecified
TXI60333Medicare UPIN