Provider Demographics
NPI:1205881919
Name:FLUKE-AGOSTINO, KAREN M (PAC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:FLUKE-AGOSTINO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:M
Other - Last Name:AGOSTINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-547-3909
Mailing Address - Fax:607-547-6325
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3909
Practice Address - Fax:607-547-6325
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02559300Medicaid
NY02559300Medicaid
NYS51415Medicare UPIN