Provider Demographics
NPI:1073038899
Name:BANNON, BECKA I (PA)
Entity Type:Individual
Prefix:
First Name:BECKA
Middle Name:I
Last Name:BANNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4537 S NUCOR RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-7969
Mailing Address - Country:US
Mailing Address - Phone:765-362-3579
Mailing Address - Fax:877-558-9529
Practice Address - Street 1:4537 S NUCOR RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-7969
Practice Address - Country:US
Practice Address - Phone:765-362-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002274A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant