Healthcare Provider Details

I. General information

NPI: 1245769249
Provider Name (Legal Business Name): SAMANTHA MARIE BANSER BISSEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA MARIE BANSER

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E J AVE STE 120
GRUNDY CENTER IA
50638-2004
US

IV. Provider business mailing address

101 E J AVE STE 120
GRUNDY CENTER IA
50638-2004
US

V. Phone/Fax

Practice location:
  • Phone: 319-824-6945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO-05233
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: