Healthcare Provider Details

I. General information

NPI: 1497255566
Provider Name (Legal Business Name): MARISA NICOLE BANKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 EXPOSITION BLVD STE 103
SACRAMENTO CA
95815-5149
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-731-7728
  • Fax:
Mailing address:
  • Phone: 629-203-7858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64025
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3450
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: