Provider Demographics
NPI:1720181803
Name:OHTA-AGRESTA, MIWAKO (CNM)
Entity Type:Individual
Prefix:
First Name:MIWAKO
Middle Name:
Last Name:OHTA-AGRESTA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NEWELL RD
Mailing Address - Street 2:D28
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010
Mailing Address - Country:US
Mailing Address - Phone:860-584-4240
Mailing Address - Fax:860-585-5852
Practice Address - Street 1:25 NEWELL RD
Practice Address - Street 2:D28
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-584-4240
Practice Address - Fax:860-585-5852
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000085367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NPP000Medicare UPIN