Provider Demographics
NPI:1700987542
Name:AGAN, JEFFERY A (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:A
Last Name:AGAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7594
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0594
Mailing Address - Country:US
Mailing Address - Phone:252-443-9103
Mailing Address - Fax:252-451-9032
Practice Address - Street 1:1223 JULIAN R ALLSBROOK HWY
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-5126
Practice Address - Country:US
Practice Address - Phone:252-537-1215
Practice Address - Fax:252-537-1816
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8770225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211214Medicaid
NC7714417OtherAETNA
NC650023761OtherRAILROAD MEDICARE
NC078PAOtherBCBS
NC195519OtherMEDCOST
NC7714417OtherAETNA
NC2504073Medicare PIN
NC2504073CMedicare PIN
NC2504073DMedicare PIN