Provider Demographics
NPI:1992965891
Name:BENCITO, EVAGRIO PAGKALIWANGAN (NP)
Entity type:Individual
Prefix:MR
First Name:EVAGRIO
Middle Name:PAGKALIWANGAN
Last Name:BENCITO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3564 BRENTON AVE APT E
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2063
Mailing Address - Country:US
Mailing Address - Phone:310-639-5282
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90810-1408
Practice Address - Country:US
Practice Address - Phone:310-222-3528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA565369163W00000X
CA17801364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse