Provider Demographics
NPI:1548797699
Name:BANNISTER, CARLOS (MPT)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 PEACEFUL GLEN DR
Mailing Address - Street 2:
Mailing Address - City:PFAFFTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27040-9300
Mailing Address - Country:US
Mailing Address - Phone:336-287-7941
Mailing Address - Fax:
Practice Address - Street 1:5908 PEACEFUL GLEN DR
Practice Address - Street 2:
Practice Address - City:PFAFFTOWN
Practice Address - State:NC
Practice Address - Zip Code:27040-9300
Practice Address - Country:US
Practice Address - Phone:336-287-7941
Practice Address - Fax:336-287-7941
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC128792251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty