Healthcare Provider Details

I. General information

NPI: 1538523337
Provider Name (Legal Business Name): VICTOR EFANGA LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6293 W PORT AVE
MILWAUKEE WI
53223-4119
US

IV. Provider business mailing address

6293 W PORT AVE
MILWAUKEE WI
53223-4119
US

V. Phone/Fax

Practice location:
  • Phone: 414-446-5150
  • Fax:
Mailing address:
  • Phone: 414-446-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number318298-31
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: