Provider Demographics
NPI:1932757804
Name:BAANG, RETZAR
Entity Type:Individual
Prefix:
First Name:RETZAR
Middle Name:
Last Name:BAANG
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 1:5357 W TONOPAH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-9121
Mailing Address - Country:US
Mailing Address - Phone:560-673-7557
Mailing Address - Fax:
Practice Address - Street 1:5357 W TONOPAH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-9121
Practice Address - Country:US
Practice Address - Phone:560-673-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider