Provider Demographics
NPI:1275018764
Name:LUI, TIMOTHY ALBERT BANGAYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY ALBERT
Middle Name:BANGAYAN
Last Name:LUI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:1867 SUMMERTIME AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6236
Mailing Address - Country:US
Mailing Address - Phone:818-800-9348
Mailing Address - Fax:
Practice Address - Street 1:25751 MCBEAN PKWY STE 305
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3701
Practice Address - Country:US
Practice Address - Phone:661-799-2542
Practice Address - Fax:661-253-0248
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56078363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical