Provider Demographics
NPI:1336618040
Name:BANGERTER, BAILEY (PA-C)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BANGERTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 EL DORADO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-3436
Mailing Address - Country:US
Mailing Address - Phone:206-930-5168
Mailing Address - Fax:
Practice Address - Street 1:220 HOSPITAL DR # A-233
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2517
Practice Address - Country:US
Practice Address - Phone:707-641-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60900605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1155569OtherNCCPA
WAPA60900605OtherWASHINGTON STATE DEPARTMENT OF HEALTH
CA59535OtherCALIFORNIA PA BOARD