Healthcare Provider Details

I. General information

NPI: 1770404592
Provider Name (Legal Business Name): RADISLAV BANAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 AVENUE P APT 2C
BROOKLYN NY
11204-4178
US

IV. Provider business mailing address

295 AVENUE P APT 2C
BROOKLYN NY
11204-4178
US

V. Phone/Fax

Practice location:
  • Phone: 917-865-0196
  • Fax:
Mailing address:
  • Phone: 917-865-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number786045
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: