Provider Demographics
NPI:1780342675
Name:EVANS, BANISHA MONAY (CPT LL)
Entity type:Individual
Prefix:
First Name:BANISHA
Middle Name:MONAY
Last Name:EVANS
Suffix:
Gender:F
Credentials:CPT LL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8674 NEMEA WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3444
Mailing Address - Country:US
Mailing Address - Phone:510-859-6555
Mailing Address - Fax:
Practice Address - Street 1:8674 NEMEA WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-3444
Practice Address - Country:US
Practice Address - Phone:510-859-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPA02209141202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology