Provider Demographics
NPI:1598141681
Name:BANNON, BUD (ATC)
Entity Type:Individual
Prefix:
First Name:BUD
Middle Name:
Last Name:BANNON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 SW CAMPUS DR
Mailing Address - Street 2:09-E1
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-5056
Mailing Address - Country:US
Mailing Address - Phone:360-621-3908
Mailing Address - Fax:
Practice Address - Street 1:952 SW CAMPUS DR
Practice Address - Street 2:09-E1
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-5056
Practice Address - Country:US
Practice Address - Phone:360-621-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1602930922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer