Provider Demographics
NPI:1073649588
Name:BANKS, RYAN (MPA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BANKS
Suffix:
Gender:M
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N 1ST ST
Mailing Address - Street 2:162
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6800
Mailing Address - Country:US
Mailing Address - Phone:559-221-1107
Mailing Address - Fax:
Practice Address - Street 1:3636 N 1ST ST
Practice Address - Street 2:162
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-221-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100211OtherSTAFF NUMBER