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NPI Code Detail

MEDICARE: DR. FANNY ROSE BANGOURA M.D.

MEDICARE: DR. FANNY ROSE BANGOURA M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician44506AZ

General Provider Information

NPI Number : 1316101918
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. FANNY ROSE BANGOURA M.D.
Provider Business Mailing Address
First Line : 5055 E BROADWAY BLVD STE A100
Second Line :
City : TUCSON
State : AZ
Zip : 85711-3629
Country : US
Telephone Number : 520-382-1085
Fax Number : 520-795-0225
Provider Business Practice Location Address
First Line : 7105 N LA CHOLLA BLVD
Second Line :
City : TUCSON
State : AZ
Zip : 85741-3112
Country : US
Telephone Number : 520-547-0611
Fax Number : 520-547-0616
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/12/2008
Last Update Date : 08/20/2020

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