Basic Information
| Provider Information | |||||||||
| NPI: | 1841758018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANGERTER | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | CHRISTIAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1736 E BELLA FIORE DR | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937307053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597061612 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1141 ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936623241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598911000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2019 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95010410 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.