MEDICARE: REBECCA MARIE BANNON CPNP-PC

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	363LP0200X	Pediatric Nurse Practitioner	1140597	TX

General Provider Information

NPI Number	:	1740052026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA MARIE BANNON CPNP-PC

Provider Business Mailing Address
First Line	:	4360 THOUSAND OAKS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-2153
Country	:	US
Telephone Number	:	210-655-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4360 THOUSAND OAKS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-2153
Country	:	US
Telephone Number	:	210-655-2300
Fax Number	:

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

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	07/11/2025

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