Provider Demographics
NPI:1831561471
Name:AGTUCA, KATRINA M
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:M
Last Name:AGTUCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:M
Other - Last Name:FRANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2146
Mailing Address - Country:US
Mailing Address - Phone:631-987-9208
Mailing Address - Fax:
Practice Address - Street 1:7 GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4231
Practice Address - Country:US
Practice Address - Phone:631-987-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037716-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist