Provider Demographics
NPI:1194963280
Name:BANAGAN, MICHAELA B (NP)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:B
Last Name:BANAGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7861 MURRAY AVE
Mailing Address - Street 2:GILROY
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4604
Mailing Address - Country:US
Mailing Address - Phone:408-842-1017
Mailing Address - Fax:408-842-4186
Practice Address - Street 1:5671 SANTA TERESA BLVD
Practice Address - Street 2:SAN JOSE
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-6512
Practice Address - Country:US
Practice Address - Phone:408-284-2281
Practice Address - Fax:408-281-2857
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18329261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health