Provider Demographics
NPI:1609141878
Name:BANNING, LARRY (LMP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:BANNING
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4488 334TH PL SE
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-5800
Mailing Address - Country:US
Mailing Address - Phone:425-281-1840
Mailing Address - Fax:
Practice Address - Street 1:670 NW GILMAN BLVD
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2444
Practice Address - Country:US
Practice Address - Phone:425-427-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60256849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist