Provider Demographics
NPI:1144594755
Name:BANE, PAMELA (PEDORTHIST)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BANE
Suffix:
Gender:F
Credentials:PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-1038
Mailing Address - Country:US
Mailing Address - Phone:315-395-3872
Mailing Address - Fax:
Practice Address - Street 1:216 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-1038
Practice Address - Country:US
Practice Address - Phone:315-395-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X, 332BC3200X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No171W00000XOther Service ProvidersContractor
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment