Provider Demographics
NPI:1073082699
Name:BANZON, MARVIN CHRISTOPHER
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:CHRISTOPHER
Last Name:BANZON
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 1:7543 197TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1816
Mailing Address - Country:US
Mailing Address - Phone:718-219-6036
Mailing Address - Fax:
Practice Address - Street 1:22215 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3678
Practice Address - Country:US
Practice Address - Phone:718-225-1414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333430-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse