Basic Information
| Provider Information | |||||||||
| NPI: | 1548242662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANGS | ||||||||
| FirstName: | KENNETH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6042N FRESNO ST 203 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937105279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594351897 | ||||||||
| FaxNumber: | 5594351667 | ||||||||
| Practice Location | |||||||||
| Address1: | 1247 E ALLUVIAL AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594316226 | ||||||||
| FaxNumber: | 5594409005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 10049 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0170299 | 01 | CA | STATE OF WASHINGTON | OTHER | 500030488 | 01 | CA | RAIL ROAD MEDICARE | OTHER |