Provider Demographics
NPI:1225400146
Name:RUNGRUANGBANGCHAN, PAVEENA (NP)
Entity Type:Individual
Prefix:
First Name:PAVEENA
Middle Name:
Last Name:RUNGRUANGBANGCHAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 DAINES DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-2133
Mailing Address - Country:US
Mailing Address - Phone:626-696-5156
Mailing Address - Fax:626-300-0056
Practice Address - Street 1:330 S GARFIELD AVE
Practice Address - Street 2:STE 268
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3892
Practice Address - Country:US
Practice Address - Phone:626-696-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2014036857363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2014036857OtherNURSE PRACTITIONER