Provider Demographics
NPI:1578539730
Name:BANNISTER, KYRA HEATHER (MD)
Entity Type:Individual
Prefix:DR
First Name:KYRA
Middle Name:HEATHER
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:570-887-4464
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044464E207L00000X
NY162645-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01070084Medicaid
NYCC8362OtherRR MEDICARE GROUP
NYP00693905OtherRR MEDICARE PIN
PA050075742OtherRR MEDICARE PIN
CC9269OtherRR MEDICARE GROUP
PA0011740400001Medicaid
PAGU039832OtherMEDICARE GROUP
PA0011740400001Medicaid
PAGU039832OtherMEDICARE GROUP
NY01070084Medicaid