MEDICARE: KATHERINE MARY BANICK PA-C

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	363A00000X	Physician Assistant	PA13117	TX

General Provider Information

NPI Number	:	1992348676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE MARY BANICK PA-C

Provider Business Mailing Address
First Line	:	4400 AVENUE N APT 61
Second Line	:
City	:	GALVESTON
State	:	TX
Zip	:	77550-6587
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11500 SPACE CENTER BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77059-3603
Country	:	US
Telephone Number	:	281-324-8077
Fax Number	:

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

Provider Enumeration Date	:	10/24/2019
Last Update Date	:	10/24/2019

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Directions to “ KATHERINE MARY BANICK PA-C” Practice Location

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