Basic Information
| Provider Information | |||||||||
| NPI: | 1114654225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANG | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | TYSON | ||||||||
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| Credential: | RN, DNP, PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980325709 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | KENT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980325709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538337444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | RN60968949 | WA | N | Nursing Service Providers | Registered Nurse | Community Health | 363LP0808X | AP61330216 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.