Provider Demographics
NPI:1023728540
Name:NDEBANGWEN, ROLAND
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:
Last Name:NDEBANGWEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11116 NIGHT CAMP DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-6113
Mailing Address - Country:US
Mailing Address - Phone:737-296-4201
Mailing Address - Fax:
Practice Address - Street 1:11116 NIGHT CAMP DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-6113
Practice Address - Country:US
Practice Address - Phone:737-296-4201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX920941631Medicaid