Provider Demographics
NPI:1609034453
Name:BANKNELL, MISTY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:NICOLE
Last Name:BANKNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:BANKNELL
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2400 BELLEVUE RD STE 21A
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2890
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:230 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3418
Practice Address - Country:US
Practice Address - Phone:478-453-8484
Practice Address - Fax:478-452-0987
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005333363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00644516OtherRR MEDICARE PIN
GA005333OtherSTATE LICENSE
GA005333OtherSTATE LICENSE