Healthcare Provider Details

I. General information

NPI: 1205976487
Provider Name (Legal Business Name): SEAN PATRICK ALONZA BANNISTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 NW FEDERAL HWY
STUART FL
34994-1016
US

IV. Provider business mailing address

745 NW FEDERAL HWY
STUART FL
34994-1016
US

V. Phone/Fax

Practice location:
  • Phone: 772-247-7545
  • Fax: 772-264-3272
Mailing address:
  • Phone: 772-247-7545
  • Fax: 772-264-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105846
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: