Basic Information
| Provider Information | |||||||||
| NPI: | 1477936326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGNEW | ||||||||
| FirstName: | CHELSEA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118A OAKWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | MADISONN HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348468421 | ||||||||
| FaxNumber: | 4348462655 | ||||||||
| Practice Location | |||||||||
| Address1: | 118A OAKWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245723001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348468421 | ||||||||
| FaxNumber: | 4348462655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2015 | ||||||||
| LastUpdateDate: | 10/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108790 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 272810084 | 01 | FL | TAX ID | OTHER |