Provider Demographics
NPI:1740629047
Name:BANSIL, DENNIS JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:JOHN
Last Name:BANSIL
Suffix:
Gender:M
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 1:22 CORPORATE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7985
Mailing Address - Country:US
Mailing Address - Phone:949-722-7038
Mailing Address - Fax:949-630-4900
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-7038
Practice Address - Fax:949-630-4900
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1106732363A00000X
CA22983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant