MEDICARE: LAURA BANNISTER DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT00009881	WA

General Provider Information

NPI Number	:	1083698070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA BANNISTER DPT

Provider Business Mailing Address
First Line	:	1612 NE 75TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-4372
Country	:	US
Telephone Number	:	206-854-1809
Fax Number	:	206-260-4565

Provider Business Practice Location Address
First Line	:	2612 3RD AVENUE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98121
Country	:	US
Telephone Number	:	206-686-4073
Fax Number	:	206-260-4565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	06/17/2013

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