Provider Demographics
NPI:1548242662
Name:BANGS, KENNETH (NP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BANGS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6042N FRESNO ST 203
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5279
Mailing Address - Country:US
Mailing Address - Phone:559-435-1897
Mailing Address - Fax:559-435-1667
Practice Address - Street 1:1247 E ALLUVIAL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2686
Practice Address - Country:US
Practice Address - Phone:559-431-6226
Practice Address - Fax:559-440-9005
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA10049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0170299OtherSTATE OF WASHINGTON
CA500030488OtherRAIL ROAD MEDICARE
CA500030488OtherRAIL ROAD MEDICARE
CAZZZ18605ZMedicare ID - Type Unspecified