Provider Demographics
NPI:1841419694
Name:AGBONTAEN, XIAONIAN JANE (PA)
Entity Type:Individual
Prefix:
First Name:XIAONIAN
Middle Name:JANE
Last Name:AGBONTAEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3609
Mailing Address - Country:US
Mailing Address - Phone:718-780-3000
Mailing Address - Fax:
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
138690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02239114Medicaid
NY4F9561Medicare ID - Type Unspecified
NY02239114Medicaid