Provider Demographics
NPI:1144621053
Name:BANKS, LORA (PA-C)
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:BANKS
Suffix:
Gender:F
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 1:14050 NW 14TH ST STE 190
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2851
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:
Practice Address - Street 1:2105 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2409
Practice Address - Country:US
Practice Address - Phone:334-213-6255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALTA1776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant