Provider Demographics
NPI:1477038354
Name:BACANI, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BACANI
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 1:4506 N BANNER DR APT 3
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-1859
Mailing Address - Country:US
Mailing Address - Phone:951-941-7690
Mailing Address - Fax:
Practice Address - Street 1:4506 N BANNER DRIVE APT 3
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807
Practice Address - Country:US
Practice Address - Phone:951-941-7690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA808705163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse