Provider Demographics
NPI:1356672612
Name:BANEK, RAFAL BOGUSLAW (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RAFAL
Middle Name:BOGUSLAW
Last Name:BANEK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL MEDICAL CTR
Mailing Address - Street 2:34800 BOB WILSON DR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:619-532-8943
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CTR
Practice Address - Street 2:34800 BOB WILSON DR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-532-8943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041313599163W00000X
CA733392163W00000X
CA3896367500000X
WI6444-33367500000X
IL209.011204367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse