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General NPI Number Information
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NPI Number | 1831932243
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Entity Type | Individual
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Provider Name | BRETT BANKSTON PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/13/2024
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Last Update Date | 06/14/2024
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Provider Practice Location Address
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Address Line | 8888 SUMMA AVE FL 3
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City | BATON ROUGE
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State | LA
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Zip | 70809-3772
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Country | US
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Telephone | 225-763-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 18023 OLD TRAIL DR
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City | PRAIRIEVILLE
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State | LA
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Zip | 70769-5586
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Country | US
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Telephone | 225-276-3618
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1197616
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License Number State | LA
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