Healthcare Provider Details

I. General information

NPI: 1629732946
Provider Name (Legal Business Name): TIMOTHY BANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2021
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date: 03/05/2025
Reactivation Date: 03/28/2025

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

47 PLATEAU
ALISO VIEJO CA
92656-8027
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95132765
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95032634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: