Provider Demographics
NPI:1285659656
Name:BANSE, RICHARD R (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:R
Last Name:BANSE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 W WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:ARANSAS PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78336-4711
Mailing Address - Country:US
Mailing Address - Phone:361-758-5199
Mailing Address - Fax:361-758-9227
Practice Address - Street 1:2150 W WHEELER AVE
Practice Address - Street 2:
Practice Address - City:ARANSAS PASS
Practice Address - State:TX
Practice Address - Zip Code:78336-4711
Practice Address - Country:US
Practice Address - Phone:361-758-5199
Practice Address - Fax:361-758-9227
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069839225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1427437-01Medicaid
TX84182TOtherBLUE CROSS BLUE SHIELD
TXP00006124Medicare PIN
TX1427437-01Medicaid