Provider Demographics
NPI:1093804460
Name:BANKS, HEATHER S (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:S
Last Name:BANKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6750 BUGLE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3869
Mailing Address - Country:US
Mailing Address - Phone:505-353-2591
Mailing Address - Fax:
Practice Address - Street 1:5495 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1200
Practice Address - Country:US
Practice Address - Phone:720-848-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24027207Q00000X
CODR.0038923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
067463011OtherREGENCE
M066524OtherPACIFIC SOURCE
911019392OtherCOMMERCIAL
OR286290Medicaid
M066524OtherPACIFIC SOURCE
R114240Medicare ID - Type Unspecified