Basic Information
| Provider Information | |||||||||
| NPI: | 1457865529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANAG | ||||||||
| FirstName: | EVA DONNA | ||||||||
| MiddleName: | MANGLICMOT | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 GRASSMERE AVE | ||||||||
| Address2: | |||||||||
| City: | OCEAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077124227 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 ROUTE 33 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077534859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327764307 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2017 | ||||||||
| LastUpdateDate: | 11/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 26NJ00780700 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.