Provider Demographics
NPI:1982394193
Name:AGONOY, JHUN DANIELE GRUESO (PTA)
Entity Type:Individual
Prefix:
First Name:JHUN DANIELE
Middle Name:GRUESO
Last Name:AGONOY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:JD
Other - Middle Name:GRUESO
Other - Last Name:AGONOY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:655 S WILLOW ST STE 128
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5723
Mailing Address - Country:US
Mailing Address - Phone:603-681-9294
Mailing Address - Fax:888-979-6551
Practice Address - Street 1:3838 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-2224
Practice Address - Country:US
Practice Address - Phone:503-357-1706
Practice Address - Fax:503-270-5023
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10156225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant