MEDICARE: MARISA NICOLE BANKS PA-C

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
1	363A00000X	Physician Assistant	3450	TN

General Provider Information

NPI Number	:	1497255566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA NICOLE BANKS PA-C

Provider Business Mailing Address
First Line	:	6746 CHARLOTTE PIKE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-4204
Country	:	US
Telephone Number	:	629-203-7858
Fax Number	:

Provider Business Practice Location Address
First Line	:	6746 CHARLOTTE PIKE
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-4204
Country	:	US
Telephone Number	:	629-203-7858
Fax Number	:	629-203-7858

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/15/2018
Last Update Date	:	08/30/2021

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