Healthcare Provider Details

I. General information

NPI: 1194963280
Provider Name (Legal Business Name): MICHAELA B BANAGAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2009
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5671 SANTA TERESA BLVD SAN JOSE
SAN JOSE CA
95123-6512
US

IV. Provider business mailing address

7861 MURRAY AVE GILROY
GILROY CA
95020-4604
US

V. Phone/Fax

Practice location:
  • Phone: 408-284-2281
  • Fax: 408-281-2857
Mailing address:
  • Phone: 408-842-1017
  • Fax: 408-842-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number18329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: