Provider Demographics
NPI:1497055396
Name:BANISTER, JONATHAN (MT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BANISTER
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-3306
Mailing Address - Country:US
Mailing Address - Phone:530-249-5352
Mailing Address - Fax:
Practice Address - Street 1:112 E 12TH ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-3306
Practice Address - Country:US
Practice Address - Phone:530-249-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist