MEDICARE: MR. JOHN J BANIA PTA

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	225200000X	Physical Therapy Assistant	PTA 2279	AR

General Provider Information

NPI Number	:	1902101322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN J BANIA PTA

Provider Business Mailing Address
First Line	:	1801 FOREST HILLS BLVD
Second Line	:	STE# 205
City	:	BELLA VISTA
State	:	AR
Zip	:	72715-3016
Country	:	US
Telephone Number	:	479-855-9348
Fax Number	:	479-855-9358

Provider Business Practice Location Address
First Line	:	1801 FOREST HILLS BLVD
Second Line	:	STE# 205
City	:	BELLA VISTA
State	:	AR
Zip	:	72715-3016
Country	:	US
Telephone Number	:	479-855-9348
Fax Number	:	479-855-9358

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

Provider Enumeration Date	:	01/14/2011
Last Update Date	:	01/14/2011

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