Provider Demographics
NPI:1780683441
Name:NALL, AGNES V (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:V
Last Name:NALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 MANATEE AVE W
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8604
Mailing Address - Country:US
Mailing Address - Phone:941-748-2455
Mailing Address - Fax:941-746-4554
Practice Address - Street 1:701 MANATEE AVE W
Practice Address - Street 2:SUITE 202
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8604
Practice Address - Country:US
Practice Address - Phone:941-748-2455
Practice Address - Fax:941-746-4554
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0062805207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL923602OtherAETNA PROVIDER NUMBER
FL32543OtherBCBS PROVIDER NUMBER
FL32543OtherBCBS PROVIDER NUMBER
FLG40536Medicare UPIN