Basic Information
| Provider Information | |||||||||
| NPI: | 1013296490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGNEW | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | CASSELBERRY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP, DNP. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASSELBERRY | ||||||||
| OtherFirstName: | MARIE | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19075 NW TANASBOURNE DR. | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039413753 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 929 SW SIMPSON AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413897741 | ||||||||
| FaxNumber: | 5412788376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 12/28/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201250123NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 201250123NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.