Provider Demographics
NPI:1972343663
Name:SIAW, AGOSTINO
Entity type:Individual
Prefix:
First Name:AGOSTINO
Middle Name:
Last Name:SIAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 BROWNS MILL ROAD
Mailing Address - Street 2:STE 6 # 333
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-408-2778
Mailing Address - Fax:
Practice Address - Street 1:3101 BROWNS MILL ROAD
Practice Address - Street 2:STE 6 # 333
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-408-2778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN119299284343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)