Provider Demographics
NPI:1184614414
Name:VIRGA, AGNES (M D)
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:VIRGA
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MASS AVE
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3739
Mailing Address - Country:US
Mailing Address - Phone:978-263-2898
Mailing Address - Fax:978-263-3305
Practice Address - Street 1:411 MASS AVE
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-3739
Practice Address - Country:US
Practice Address - Phone:978-263-2898
Practice Address - Fax:978-263-3305
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80633204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3155706Medicaid
MAG27466Medicare UPIN
MA3155706Medicaid