Provider Demographics
NPI:1598747891
Name:BANWART, LEO A (PA-C)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:A
Last Name:BANWART
Suffix:
Gender:M
Credentials:PA-C
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 668
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-0668
Mailing Address - Country:US
Mailing Address - Phone:319-768-3628
Mailing Address - Fax:319-768-3633
Practice Address - Street 1:1221 S GEAR AVE
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655
Practice Address - Country:US
Practice Address - Phone:319-768-3628
Practice Address - Fax:319-768-3633
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001088146N00000X
IA0010881207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA49776OtherBX
IA930097503OtherRR MC
IA49776OtherBX
IA930097503OtherRR MC