Provider Demographics
NPI:1942955166
Name:AGOSH, MICHAEL A (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:AGOSH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 W GENESEE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3260
Mailing Address - Country:US
Mailing Address - Phone:315-468-1050
Mailing Address - Fax:315-468-1201
Practice Address - Street 1:601 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3614
Practice Address - Country:US
Practice Address - Phone:315-452-5580
Practice Address - Fax:315-452-5303
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013092225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant