Provider Demographics
NPI:1568811024
Name:BANCHUIN, PETE (MD)
Entity Type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:BANCHUIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:1000 WILLOW CREEK RD STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-493-0007
Practice Address - Fax:928-445-5412
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL0006259207Q00000X
AZ59230207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine