Provider Demographics
NPI:1003195306
Name:BANIRE, ABDUL LATIF (PA-C)
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:LATIF
Last Name:BANIRE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:859-572-3617
Mailing Address - Fax:859-572-2366
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1793
Practice Address - Country:US
Practice Address - Phone:859-572-3618
Practice Address - Fax:859-572-2366
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1650363A00000X
INPA1650363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047753Medicaid
KY7100229590Medicaid