MEDICARE: AMY SUE BANAHAN NP

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	207Q00000X	Family Medicine Physician	354268	NY

General Provider Information

NPI Number	:	1265278758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY SUE BANAHAN NP

Provider Business Mailing Address
First Line	:	551 OLD QUARRY RD
Second Line	:
City	:	SELKIRK
State	:	NY
Zip	:	12158-2109
Country	:	US
Telephone Number	:	518-801-7286
Fax Number	:

Provider Business Practice Location Address
First Line	:	1499 NEW SCOTLAND RD
Second Line	:
City	:	SLINGERLANDS
State	:	NY
Zip	:	12159-9209
Country	:	US
Telephone Number	:	518-801-7285
Fax Number	:

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

Provider Enumeration Date	:	07/03/2024
Last Update Date	:	07/03/2024

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