Healthcare Provider Details

I. General information

NPI: 1336183458
Provider Name (Legal Business Name): THOMAS DOAK BANNISTER IV RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 BEDFORD RD
BEDFORD TX
76022-5201
US

IV. Provider business mailing address

11 FAIR GREEN DR
TROPHY CLUB TX
76262-5630
US

V. Phone/Fax

Practice location:
  • Phone: 817-268-0104
  • Fax:
Mailing address:
  • Phone: 817-683-8818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number679878
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: