Provider Demographics
NPI:1417912072
Name:BANNER, TAMMRA JOY (OD)
Entity Type:Individual
Prefix:
First Name:TAMMRA
Middle Name:JOY
Last Name:BANNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TAMMRA
Other - Middle Name:JOY
Other - Last Name:SHERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:413 GERMANTOWN PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1816
Mailing Address - Country:US
Mailing Address - Phone:610-825-7980
Mailing Address - Fax:610-825-5398
Practice Address - Street 1:413 GERMANTOWN PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1816
Practice Address - Country:US
Practice Address - Phone:610-825-7980
Practice Address - Fax:610-825-5398
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00537200152W00000X
PAOEG000598152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU72795Medicare UPIN