Provider Demographics
NPI:1366445975
Name:DELANEY, AGNES BLANCHE (PA)
Entity type:Individual
Prefix:MS
First Name:AGNES
Middle Name:BLANCHE
Last Name:DELANEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 WH SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3763
Mailing Address - Country:US
Mailing Address - Phone:527-583-2112
Mailing Address - Fax:
Practice Address - Street 1:850 WH SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3763
Practice Address - Country:US
Practice Address - Phone:252-758-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002145363A00000X, 363A00000X
NC001009744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85002145OtherSTATE LICENSE
ILK19302Medicare PIN
IL214881Medicare Oscar/Certification