Provider Demographics
NPI:1215044532
Name:BANICKI, SHARON ANN (ANP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:ANN
Last Name:BANICKI
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19739 WAR ADMIRAL RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577
Mailing Address - Country:US
Mailing Address - Phone:907-696-1697
Mailing Address - Fax:
Practice Address - Street 1:1200 AIRPORT HEIGHTS DR
Practice Address - Street 2:SUITE 280
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-339-9700
Practice Address - Fax:907-339-9720
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK584363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
C98331Medicare UPIN
K000BHJPRMedicare ID - Type Unspecified